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Home My WebLink AboutBLDX-25-815- �� Y-- Office Use Only j i Amount — EXPRESS BUILDING PERMIT APPLICAT, o TOWN OF YARMOUTH E C i E D Yarmouth Building Department • j 1146 Route 28 Jii 23 025 South Yarmouth,MA 02664 G (508)398-2231 Ext. 1261 S a DILDING D�=r CONSTRUCTION ADDRESS: (� S y1'I f 7/1 it t? r - tit/ / oR'c6- OWNER: E.4. ) J//S - 1 - __ J Li/- ._— 7/C1 Y-6 s. 37/7 N A\IE PRE. :NT ADDRESS TEL a CONTRACTOR: Se__1� N\\II NI:\UM/ADDRESS TEL.e • EMAIL: I ee asiJrntial J Commercial Est.('ost of Construction S /y�j r�. Homeowner is Applicant? l'es 1/ No Home Improvement Contractor Lie.# Construction Supervisor Lic.# WORK TO BE PERFORMED • Tent Duration 3 (Fire Retardant Certificate required) Wood Stove Siding: #of Squares c56.e. Replacement windows:# Replacement doors: # Roofing: #of Squares Insulation Temporary Mobile Home_ Temporary.Construction Trailer Demolition-Interior only 'Demolition Raze Structure Solar System ESS System Chimney Fence `Please submit utility disconnect letters for electric&gas-structures over 75 s ears old require historical review i i ` / 'The debris will be disposed at: -of at: Locale Facillty I declare under penalties of perjury that the statements herein contained are true and correct to the hest of my knowledge and belief. I understand that any false:Ms,eri.l will be just cause kw denial or rcs-oeafi�n of my license and under M.t i I.Ch.Ifi%.Section I. / / Applicant's Signature C Date: ‘ 2 S Owners Signature for attachment) Date; Approsed By- Date Budding Official for desigmeel ---- - Res 6 21 _ .114 - . .; • - ltefr) , • ' ANA gSi ' - k. _0 cl•\. The Commonwealth of Massachusetts Department of Industrial Accidents ± ►- Office of Investigations Lafayette City Center _. 1i —�_— 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): p Address: /7/6 City/State/Zip: PhoneAre you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. ❑ I am a general contractor and I 2. �Imployees (full and/or part-time).* have hired the sub-contractors 6. ❑ New construction 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' [No workers' comp. insurance comp. insurance.: 9. ❑ Building addition required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.0/ 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 ❑ Roof repairs insurance required.] t c. 152, §1(4), and we have no 13.❑ Other �j,a� �,� l employees. [No workers' / 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 providingworkers'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 pedury that the information provided above is true nd correct. Signature: CP---A"te-) Date: ' / c.3 Phone #: S'7 '5/ 7 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): 10Board of Health 21:Building Department 312City/Town Clerk 4.0 Electrical Inspector 50Plumbing Inspector 6.0Other Contact Person: Phone #: 1 }�_r giMSp y•' 41Jpt.' 41' ti_a • 4 • ait fsr S