The URL can be used to link to this page

Home My WebLink AboutBLDX-23-15165 Q/ey ;Office Use Only j.}9Ro RECEIVED merA-Aj Permit# p• .,,a. 1 1' :��y /[/ /e1� 3 1Amount q 0 ` MATTACe� � LA1JG 2023 �" -1 t� to m a/1 !Permit expires 180 days from issue date BUILDING DEPARTMENT el c nY1D . . JJ y SY:— —+—^:— d ei {[ `7 EXPRESS BUILDING PERMIT APPLICATION `,� (�JC� TOWN OF YARMOUTH r G is H -e�Pi r' -112�.)� Yarmouth Building Department )( -7 ,_) -;�j , 1146 Route 28 , 4I3(.1 '`G� (.l`�- South Yarmouth, MA 02664 tO (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: I71k 40 I b 'I/j 1 `'c 1 c? ASSESSOR'S INFORMATION: Map: Parcel: " OWNER: 7-hn 1( D LA.)l°GC5 I`P _ PRESENT ADDRESSI�CJLJ NSCC,b— L E6�7 CONTRACTOR [) it LL IC' 17 Z 0 t b wick 1i\i 7S 1-C)2 V3.0 27a$7 —NAME MAILING ADDRESS TEL.# ❑Residential 0 Commercial Est.Cost of Construction$ l.0 00 Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) 1p,TVam the homeowner ❑ I am the sole proprietor ❑ I have Worker's Compensation Insurance Insurance Company Name: t ' jVl'Cp i t (I . N 5 Worker's Comp.Policy# WORK TO BE PERFORMED Dori��i �� Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows: # Replacement doors: # Roofing: #of Squares ( ) Remove existing* (max. 2 layers) Insulation )5...4.)' v Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: liC r -L Ti c Ut'l cp Location of Facility I declare under penalties of perjury 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 denial or r vocation of m lic e and for pr ecution under M.G.L.Ch.268,Section 1. Applicant's Signature: I/ Date: • Owners Signature(or attachment) Date:Approved By: .�� Q Date: C�A/3 Building Official(or designee) EMAIL ADDRESS: ing District: L� Historical District: ❑ Yes No Flood Plain Zone: ❑ Yes ❑ No <ra Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes ❑ No • `'�''� The Commonwealth of Massachusetts n i (t Department oflndustrialAccidents • 1 Congress Street,Suite 100 :- �" Boston,MA 02114-2017 H _� www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO B FILED I1THE PE&DfiTTJ�feIA` k1TyARITY. Applicant Information I I « Please Print Legibly Name(Business/Organization/Indiv' �, r:-. Address: l Z ) ) aAyl l az Ci. /State/Zi 42f fY- y M !34 (!� tY p Phone#: } Are you an employer?Check the appropriate box: Type of project(required): 1.0 l am a employer with employees(full and/or part-time).' 7. ❑New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.[No workers'comp.insurance required.] � - 'X1 am a homeowner doing all work myself[No workers'comp.insurance required.]t 9. LKuemolition 10 ElBuilding addition I am a homeowner and will be hiring contractors to conduct all work on my property.I will ensure that at contractors either have workers'compensation insurance or are sole 1 I.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] •Any applicant that checks box#1 must also fill outihe section below showing their workers'compensation policy 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 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 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 information. Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: 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 MGL c.152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify u1nder�tlte airs an Haloes of perjury that the information provided above is true and correct. Signature: +t-/ i Date: — /1 —2 02S Phone#: Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# 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#: