HomeMy WebLinkAboutBSHD-25-2 - Applicationo'- . .'-lL .
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EXPRESS SHED PERMIT APPLICATION
T()\\,N OF YARMoI.-ITH
Yarmouth Building Department
| 146 Roure. 2ti
South Yannouth. \lA 0166.1
(5oti) -198-:l-1 I Exl. l26l
BS t-to - er-f
Ollicc tirc Only
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,^.,,^,35.00
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( otlstroctlon Superrisor l,ic. #
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I .llllln''l.t !!,: rtqr!!!!d kt h! lA!4t*l rlg4 r -Lq1fuyq1nr ar ln' t lot ltnt.
Rrplacc cristing*
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ltue .rnd (orr..l (r lhc br'\r nl mf ttr,.$ l.dgc .rnJ hclef llnd.^rJndrhrtrn\hl,c.nr$\..r.)
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Zo[ing Dirlrict.
Hr.roncal Dirrrrcr ./,-JJ\O
'rConrnation roicu will bt'rt'quired ifshcd is placcd $ithin lUlli of
l\cthnd, 2 )lt I'rum rircrfront. or lot'irtcrl \Iithin a flor.xl ronc..
RECEIVED
FEB 04 2025
BUILDING DEPARTMENT
Sy
II L ,
SHED INFORTIIATION
E (brnerLot: les- ," 1
t/
r(ilit\
Workers' Compensation Insu rance Affidavit: Builders/Contractors/Electricians/Plumbers
A licant Info o Please Prin L bl
Name (BusinesgOrganization/lndividual):
Address:s
:-\
L-..-
l--
Ci ratclzi 6rl Phone#: 5-O?7 U
r.{.ny ,pplicanl fial ch.cks bor ,l musl also fill oul thc sGtlon bclo* showing thcir llor}icrs comp.nsrtron policy information.r Homeor+ncrs *ho submil this affida!il indicaling lhc, arc domg all sorl and rhcn hirc oursrde contractors musr submit a nc\r affida\ lt tndicaling suchlconracbrs thal chc.l thrs bor must attached an addilional shctt sho\+in8 the namc of thc sub-conractors and slarc whether or not lhosc mritics hare
cmployccs. If thc suEcontraclors havc employccs. thcy must providc th.ir workcrs'comp. policy numb6.
I 4m an emploler thot is providing twrkerc' compensation insurance lor my employees. Below k the policf and job site
inlormation
Insurance Company Nu*t
Policy # or Self-ins. Lic. #:_ Expiration Date:_
Yo,-Tf.
Job Sire Address
Attach a copy o
Failure to secure
City/Srare/Zip:---'-
f the workers' compcnsalioo polic.r- declaretion pege (shoBing thc policy number and erpirrtion date).
coverage as required Section 25A ofMGL c. 152 can lead to the imposition ofcriminal penalties ofa
fine up to S1,500.00 and./or
ofup lo S250.00 a day agail
one-mpnsonmenr, as well as civil penalties in the form of a STOP WORK ORDER and a fineviolator. Be advised that a copy of this slatement rnay b€ forwarded to the Office of
lnvestigations of the DI insurance coverage verifi cation.
I do hereby certifi'the ptins and penalties ofperju1' thtt the inlormstion provided oboye is true snd correct.
Si
Are vou an employer? Check the eppropriste box:
l.! I am a employer with
-
4 ! I am a general conlractor and I
employees (full and/or part-time).t have hired the sub-contractors
2.! Iam a sole proprietor or partner- listed on th€ attached sheet'
ship and have no employees These sub-contractors have
working for me in any capaciry. ernployees and have u'orkers'
[No workeTs' comp. insurance comp lnsurance '
rJ{tired.l 5' ! We are a corporation and its
3.V am a homeowner doing all work officers have exercised their
myself. [No workers' comp. right ofexemption per MGL
insurance required.] r c l52' $l(4)' and we have no
employees. [No workers'
comp. insurance required.]
Typ€ of projccr (required):
6. ! New construction
7. ! nemodeling
8. ! Demolition
9. I Building addition
lO.! Elecrical repairs or additions
I l.! Plumbing repairs or additions
12.! Roofrepairs
l3.E Other
se onl!. Do ,tot b'rite in this oreo, lo be completed b! city or torn ollicial.
ilding Departmenr 3ECityllown Clerk 4,E Ebctrical Inspcctor SEhlumbing
Issu
t
ing Authoritr- (check one
Board of Health zE nu
Phone #:
C To11n:permiUlicense #
The Commonweolth of Massachusetts
Departm ent of I nd ustrial Accidents
Ofice of Investigations
Lafayette City Center
2 Avenue de Lafayette, Boston, MA 02lll-1750
wrty.mossgov/dia
Lo t-,-
Inspector 6.flOther
Contrct Person: