HomeMy WebLinkAbout71-77 South Street Express Building Permit Application 12.16.20147r 17 50-7�-H s G ';sue/
Officelise only
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Amount
Permit expires 180 days from
EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department 1146 Route 28COV
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS:
ASSESSOR'S INFORMATION: i S of `^ 6
Map: LlParcel:
OWNER: ti� r� �1�u� 044�q"A
NAME PRESENT ADDRESS TEL. # Email Address:
CONTRACTOR: � _ . � �� s7 ��'1 04 ffi cr\c5 U0 Sc 1,_� - y 3 a
NAME MAILING ADDRESS TELJAA #
yG�C �i���, Email Addre
E�D
Commercial Est. Cost of Construction C
Home Improvement Contractor Lie. # l d. Construction Supervisor Lic. # `' *�
Workman's Compensation Insurance: (check one) ( - -
be
I am the homeowner I am the sole proprietor I have Worker's Compensation Insurance �./
Insurance C O d Company -- - (f__ ice} C S 5 C) G o S �O t
p y Name: ��`� 0��� V'���t Worker's Comp. Policy#
WORK TO BE PERFORMED
Tent Duration (Fire Retardant Certificate attached`?}
Siding: # of Squares Replacement windows: #
Roofing: # of Squares ( ) Remove existing* (max. 2 layers)
Old Kings Highway/Historic Dist. � '�RepJacin�g� f� like
*Tbe debris will be disposed of at:
f Mo:,' 1 Ow n i
I declare under penalties of perjury that the statements herein cc
will be just cause for denial or revocation of my license and for
Applicant's Signature: tk/ /2,— � r
Owners Signature (or
Approved By:,
Building Official (or designee)
RECC`EI E
DEC 17 2014 i
ti 1�I�CFIi� I Ills ,YT
I
of Facility
Wood Stove
Replacement doors: #.
Insulation
��.
are true and correct to the best of my knowledge and belief. I understand that any false answer(s)
:ion under M.G.L. Ch. 268, Section 1.
Zoning Distric
Historical District: Yes N®
Water Resource Protectt istrict:
Yes to
Date: X 0- ` t o` III _
(Z /7- Iq
Date:
K-:> —7
Flood Plain Zone: Y�e No
Within 100 ft. of Wetly:
Yes o
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electriciansiplumbers
Applicant Information 1 Please Print Legibly
Name (Business/Organization/Individual): r\ C{'� ;O �CSM@S
Address:'Jwjr�rCcAk CSACc�
Ci
Phone #:
Are y u an employer? Check the appropriate box:
1. 1 am a employer with4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the subcontractors
2. ❑ I am a sole proprietor or partner- listed on the attached sheet
ship and have no employees
working for me in any capacity.
[No workers' comp. insurance
required:]
3. ❑ I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
3a. ❑ I am a homeowner acting as a
general contractor (refer to n 4)
These sub -contractors have
employees and have workers'
comp. insurance_:
5. ❑ We are a corporation and its
officers have exercised their
right of exemption per MGL
c. 152, § 1(4), and we have no
employees. [No workers'
coma, insurance reauired.l.
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. 1110emolition
9. [] Building addition
10.❑ EIectrical repairs or addition
11.0 Plumbing repairs or additior.
12.❑ Roof repairs
13.❑ Other
"Any applicant that checks box #1 must also fill out the section below showing their workers' compenmtioupolicy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box trust 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 must provide their workers' comp. policy number_
I am an employer that is providing workers' compensation insurance for my employees Below is the policy and job site
infOrmatlon. 5
Insurance Company Name:
Policy # or Self -ins. Lic. #: W C 5C3
�C� �� O
C�
Expiration Date: [U — oZ �,
Job Site Address: �' '^ S� S-
`� C �`'` V ^
M
City/State zip:
Attach a copy of the workers' compensation policy 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 51
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.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct
Si ature: j{-..,v Date:--
- b`A8- E `-i 3),
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. EIectrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
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Wednesday, Dec 17, 2014 0' :07 PM