HomeMy WebLinkAboutApplicationo
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TOWN OF YARMOUTH
Yarmouth Building Department
I146 Route 28
South Yarmouth, MA 02664
(508) 398-22i1 Ext. l26l
0l)ice lJse Onll
Pe,^itil ({tL) | (atil
Pcrmit erpires 180 days from
issue date
R ECEIV ED
FEB 2 8 202{
BUILDING DEPARTM ENT8v:-
jQ:ll
( )u'Nl-.R
CONI'RAC11)R
EXpRESS sHED pERMIT AppLICATIoN 65't-lD'J4- /t
CONSTRUCTI.N ADDRESS: q L/tlns L"nrz
*[,; r t"5of 5o trzt7\.\\t PRESEN T ADDRFSS 'ntl #
NA\1E ]\IAII,ING ADDRESS
Tfesidenriat ( omnrcreial
TEL #
Est. cosr orconsrrucrion g 4 SOO, p6 t/
Home lmprovement Contractor Lic. #_Construction Supervisor Lic. #
Worlmarr's Compcnsalton Insurancc: {check one)y' lam the homcosnr-r I am lhe sorc proprielor I ha\e \,torker's compensation Insurance
Insurance Company Name: Worker.s Comp. polic)#_
. SUIID INFORMATIONy'*"r,
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size L l0 x w-J-L-x u /b cornerlor: yes *o /
Pr:r 'Iinyt ol l'urnnuth Zonint! 8t-Luw, Stc 20-J.5 Note E:
,\ide u raur )unl .setha
shull hc .:it (6).li,rt i , l
othL'r huihliug tn tn ttljt
tc'k.t.for u<'c'csxtr.1' building:; ctnruirting one rntnrh..ur ./ili.t ( t 50t sLruure .fc.,r or ras.\ utkr .\ingre ,\tot1di\trict\. bur itr rro c'use slull suid u<.L.es:ory huillinig: ha huilt tioser'rhttn rrreltr t l2l f"ii tr, rnr.iltL'ctrr lturcel. All shcls ure reuuirel t<t hc loc.uted thh.0.(30tftetrront utt-t. littttt !,t litrc
Replace existing* _ Size L
+The debris will be disposed ot at
I,o f ln
.r/ep1ltcanr s srgnrturc _/ o*n..s signarrrc (or arlrchm(nt)
Approved B)
l)rtri
EMAIL ADDRESS
Zoning District
llistorical District: yes No Flood plain Zone: yes
Waler Resource Prorcction Districlj Wirhin 100 ft. ofWetlands: ***Yes No**'Nole: Conservalion revie\\ requircd if w,,n," ltot n. of w"]],a.
emL-i L" r! tra /c7'1 0 yrnto, ttn-
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en orn 35 ,0
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_ Date:
I
gurlarng flr-ficrat tt,r ac.senecr --- -- Dale
t<x \
The Commonwealth of Massachuselts
Department of Industial AccidentsI Congress Street, Suite 100
Boston, MA 02114-2017
\\:o rke rs' Co m pe ns a ti o n r rr r.",, ""11f; lj:,:::;
TO BE FILED WITH TIIE PERM
v/dia
ders/Contracto rs/Electricians/plumbers
ITTING .4TITHORJT)'.
P se P tLlitI
,came (Business/Organjzarion/lnCjv jdual):
ddress:q 0f)t()z "t,/ /h/r/
Phone #:1
applrcant that check box #l must also fill ou! tha seclion bclow showing thcirwork.rs' coEpensatjon poliry information.i11omcownen who submit this affidavit indicating thry arc doing all work and thcn hir. outsidc contracto,s must submit a ncw affidavrt indrcatlng such,:ConE_actors thar check this bor must atBchcd an additlonal shcct showing thc namc ofthc sub-contractors and stare whether or not rhosc entities haveemployecs. Ifthr sutconE-actors have Ioyecs, thcy mustemP
CitylState/Zip:
I am a.mployer with _cmployees (full and,/or pan-umc) *
1_T-i-t:l:-*:Lrl".r :r pannershrp and have no cmptoyees workrne for lr). Inany capac[y. INo workcrs' comp. insurance requircd.]
a homeowncr doing all work mysalf. [No workcrs, comp. insurancc required.] i
I aln a gcnaral contractor and I havc hircd .Jrc sub_coDE-actors listld on thE attaahcd shectThcsc sub-contracrprs havc cmployecs and hav. *ort".r, "oap.-,,irir"i;.i**"
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6 ! Wc arc a corporutio. and its omcers have c\ercBed rherr rjghr ofcxcrn152, S l (4), and wc havr no .rnploylcs. tl,lo *ork"", ;.;:;;;;
1
I
5
I
I am a homcowncr aj1d will be hiring
ensurc that all con!-actors eilhcr havc
contractors to condud al) work on rny propcny I willworkcrs' compcnsalion tnsuraace or ara solepropnetors wlth no rDployecs_
Fjon per MGL c
rcqrured.]
Arr you an employer? Ch!ck the appropriat. bor:Type of project (required)
New consitruction
Remodeling
Demolition
Building addition
Electrical repairs or additions
Plumbing repairs or additions
Roofrepairs
Other
providc thelr workcrs,comp. poljcy Dunber
I am an employet that is proyid.int worken,
informotio n-
competlsation insurance for my emplolees. Below is the policy a d job site
lnsurance Company Name:
Policy # or Self-ins. Lic. #:
Job Site Ad&ess:
Expiration Date
Attach a copy of Ciry/State/ZiP:-
Fairuretosecurecover€e".,"0,0100",1"'i.'l",l,ll:",:;:,TlT::L:.,1il:,".,::::HHnffim.i'
ard'/or one'year imprisonmenr as well as civil p*.],i., i, *. rl* of u srop wonx tiniin "#" n". of up to $250.00 a3:l."illi:#"'ir"#or' A copv ortui"tut''"ni .n"i i.'i#*i.i.,r,. orfice of lnvestisations of the DrA for insurance
do hereby under tlt ,IJ
e#
enalties ry thdt the information provided above is trui and correct.
Date JP
City or Town:
Phon e #:
cal Inspector 5. plumbing Inspector
Issuing Aurh o rity (circle one)t. Board of Health 2. Buitdin
6. Other g Department 3. City/Town Clerk 4. Electri
PermiVLicense #
Official use onl!. Do notwrite in this area,tob e complaed by city or town ofJicial
Contact Person:
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Lot #
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