HomeMy WebLinkAboutBLDX-25-307 application Office Use Only
Permi(#area)
Amount d.
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EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH RECEIVED
Yarmouth Building Department — --- - ---
1 146 Route 28 MAR 2 0 2025
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261
BUILDING DEPARTMENT
CONSTRUCTION ADDRESS: / ey:
OWNER: -q'o & iLO oL/ eI/Pq' 1`�'_Xa/a S Rd o / 3 E/355
NAMI PRESENT ADDRESS TEL. r
CONTRACTOR:
NAM!: tit\II I`G ADDRESS TEL.#
EMAIL:7.570aa A ot%b//, C®,W
Residential J Commercial Est.Cost of Construction S 3000
Homeossner is Applicant? 1'es X No
Hume Impruscnunt ( untractor/Lie.# ( (instruction tiupersisor Lic.#
WORK TO BE PERFORMED
Tent Duration (Fire Retardant Certificate required) Wood Stove
Siding: #of Squares _ Replacement ss indows: # 02 Replacement doors: #
Roofing: #of Squares Insulation Temporary Mobile Home
Temporary Construction Trailer Demolition Interior only Demolition Raze Structure
Solar System ESS System ( hinums Fence
*Please submit utilits disconnect letters for electric & gas - structures os s r 75 sears old require historical res less
*The debris will be disposed of at: fe3 Yf I m - f t S- 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 ti r denial or revocation of my license and for prosecution under M.(i L ('h.268.Section I.
Applicant's Signature Date:
Owners Signature(or attachment) Date: 63/
Approved By. Date:
Building Official(or designee/
Res 6 24
The Commonwealth of Massachusetts
if Department of Industrial Accidents
Office of Investigations
a Lafayette City Center
2 Avenue de Lafayette, Boston,MA 02111-1750
• www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): ���/ 'L/ C Y> �� c42/
Address: // vL°/Z U S O I
City/State/Zip: (j, 9' i y /2vf .i'fit Phone #: 0RY 3 g l3 S
Are you an employer? Check the appropriate box: Type of project(required):
1.El I am a employer with 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub-contractors 6. New❑ construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. employees and have workers'
9. ❑ Building addition
[No workers' comp. insurance comp. insurance.;
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3. I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.] t c. 152, §1(4),and we have no
employees. [No workers' 13.❑ Other _
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the 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.
:Contractors 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. Lic. #: 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 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.
I do hereby certify under the pains and penalties of perjury that the information provided a ove is true and correct
/Signature: ! Date: a .20/9Od
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(check one):
1❑Board of Health 2❑Building Department 312City/Town Clerk 4.0 Electrical Inspector 5E'lumbing
Inspector 6.0Other
Contact Person: Phone#: