HomeMy WebLinkAbout177 River Street Express Building Application 10.06.2014n�
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kXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664
(308) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS: a,,6- (�4 `
Office Use Only
Permit#
Amount
Permit expires 186 days from
ASSESSOR'S INFORMATION:
L Map: `lj Parcel: pt"i
OWNER: U ,5 t✓4AIt�rR, 6(b IlApi % �3 Z O
N RESENT ADD S J #
CONTRACTOR: 1 �D7� 4 o r� u SfJ—�Ai•Z'G
Email Addres
�`'�. L� MAILING ADDRESS TEL. #
N ) Email Add
Residential Commercial Est. Cost of Construction $
Home Improvement Contractor Lie. # l 7 S 3 Construction Supervisor Lic. #c9F4
Workman's Compensation Insurance: (check one)
I am the homeowner _I amthesole proprietor I have Worker's Compensation Insurance Insurance Company Name: �44 'C Worker's Comp. Policy# �✓ SDD S 7 bO :�
WORK TO BE PERFORMED
Tent Duration (Fire Retardant Certificate attached?) Wood Stove
Siding: # of Squares Replacement windows: # Replacement doors: #
Roofing: # of Squares ( } Remove existing* (max. 2 layers) Insulation
,���Old Kings Highway/Historic Dist. ( )Replacing like for like 0,,—
*The debris will be disposed of at: v w6A- r ►f i
Location of Facility
I declare under penalbe f p jury that the statements herein contained are true and correct to the best of my knowledge and belief. I understand that any false answer(s)
will be just cause for d ni re o f my license and for prosecution under M.G.L. Ch. 268, Section 1.
Applicant's Signature: yy�� Date:
T�
Owners Signature (or attachmenDate:
Approved By: Date:
Building Official (or designee)
41
Zoning District: ✓
Historical District: Yes No Flood Plain Zone: (:�Yls
No
Water Resource Prot bn Di ct: Wi . o etlands:
Yes No Yes No
1he Commonwealth of Massachusetts
fn Department of Indusoial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov1dia
Workers' Compensation Insurance Affidavit: Builders!Contractors/Electricians/Plumbers
A licant Information Please Print Legibly
Name (Business/organization/Individual):
Address:6t* 0
to
fvyr(, 0 h
Phone
Are you an employer? Check t e appropriate box:
1 I am a employer with
4. ❑ 1 am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2. ❑ 1 am a sole proprietor or partner-
listed on the attached sheet.
ship and have no employees
These sub -contractors have
working for me in any capacity.
employees and have workers'
[No workers' comp, insurance
comp• insurance.t
required:]
5. ❑ We are a corporation and its
3. ❑ I am a homeowner doing all work
officers have exercised their .
myself. [No workers' comp.
right of exemption per MGL
insurance required.] t
3a. ❑ I am a homeowner acting as
c. 152, § 1(4), and we have no
a
general contractor (refer to #4)
employees. [No workers'
comp, insurance reauired_l
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. gDemolition
9. ❑ Building addition
10. ❑ Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.❑ Roof repairs
13.❑ Other_
*Any applicant that checks box #I must also fill out the section below showing their workers' compensaticdi3olicy information.
t Homeowners who submit this affidavit indicating they are doing ati work and then hire outside contractors must submit a new affidavit indicating such.
IContracton that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have
employees. If the sub -contractors have employees. they trust provide their workers' comp. policy number.
lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information. 1 J „ ,
Insurance Company
Policy # or Self -ins. Lic. #: VU,
Expiration Date: 11
Job Site Address:
City/State/Zip:
Attack a copy of the workers' compensation !icy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $ 1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
20 1 3
I do hereby c nd r and penalties of perjury that the information provided ab ve is true and correct
Si afore: Date: N
Pion #; �0 - W7 --( I- Z
Official use only. Do not write in this area, to be completed by city or town official
City or Town: PermitlLicense #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #: