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Home My WebLink AboutBLDX-25-891 :t``FAF ii. ..O1Tice Use Only �: 0\� Permitu 3( 4 0 y; Amount tC �/ \`o• o`� I —.--- EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTII Yarmouth Building Department 1 146 Route 28 South Yarmouth,MA 02664 F� (508)398-2231 Ext. 12611 CONSTRUCTION ADDRESS: II I�-/3 ?.I -2.U-. 51M 1f15 Ce1� 5,t mic Ji\_t _C--a&I OWNER:itory gycy7n0Ai _'ro-ze _ • Gr► lt1 tllA._ `� zz 31 V\Ull- PP EESENT.\D1I`M SS_ ` 11t TEL a Ll / A CONTRACTOR:y�f/Yl(aJ�h rl 1t�fQYiPt/LL_f t( Ocri(1�{QYj , ')? D` 3 3. Vxmo,, 4 __1`,-, S\y16 //NAILI\,/\UDRES TEL. 5O.1�6/6-V�Z/6 // EM..AIL4e6L^i fl@11C(r oli.fvvA. JS x - 1()U--f�Z`"� Residential ( lf Commercial Est.Cost of Construction S /1 Homeowner is Applicant' Yes No (/ Home Improvement Contractor Lie.# Construction Supervisor Lic.# ZO i 3D (2) WORK TO BE PERFORMED Tent X_ Duration (Fire Retardant Certificate required) Wood Stove Siding: #of Squares Replacement svindotys:# 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 years old require historical review 'The debris will be disposed of at: C0.0 ( . Dax.. I 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 Use answers) will Sc just cause for denial or re: on of m)license and for prosecution under bit,I l'h.'--fig,Section I. �J Applicant's Signature, 17�� Date:—'0,7Lb Owners Signature(or attachment) Date: Approsed By: �`�:%"/ - Date: % 1 j Building Official tor designee) Re:Is 24 i The Commonwealth of Massachusetts Department of Industrial Accidents V Office of Investigations 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): Address: 612 0 (--\ Haio 5 y \1� l " fone —Ci /State/Zip: �Yl'V►C> #: /R A I3)6 Are you an employer? Check the appropriate box: Type of project(required): I.❑ 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' [No workers' comp. insurance comp. insurance.: 9. ❑ Building addition 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 m self. [No workers' comp. right of exemption per MGL yp 12.❑ Roof repairs insurance required.] t c. 152, §1(4),and we have no �employees. [No workers' 13.cZOther 7 i`` O (Z)ZC/ comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. f 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 certi er t pains and penalties of pedury that the information provided above is true and correct. Signature: / -- Date: Phone#: 7/ /X- 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 21:1 Building Department 312City/Town Clerk 4.1:Electrical Inspector 5Elumbing Inspector 6.1=10ther Phone#: Contact Person: �pJfORyiFIREp MEMi FIRE FLAME RETARDANT SINCE 1885 Fabric Registration LICENSE NUMBER: F-088001 TENT CANOPIES AND SIDEWALLS, #TT16OZBO Product Marketed by TENT AND TABLE.COM, LLC 3336 BAILEY AVENUE Issue Date : 05/22/2025 BUFFALO, NY. 14215 Expiration Date : 06/30/2026 This product meets the minimum requirements of flame resistance established by the California State Fire Marshal for products identified in Section 13115, California Health and Safety Code. The scope of the approved use of this product is provided in the current edition of the CALIFORNIA APPROVED LIST OF FLAME RETARDANT CHEMICALS AND FABRICS, GENERAL AND LIMITED APPLICATIONS CONCERNS published by the California State Fire Marshal. Okaei 6 « J.e.e. - Issued By Cortney Walker Reviewed and Approved By Patricia Setter Fire Engineering License Manager Program Coordinator Fire Engineering & Investigations Division Fire Engineering & Investigations Division OFFICE OF THE STATE FIRE MARSHAL Please visit uatcalfire.govmotus.org for more information on Licensing and Permitting with CAL FIRE Page 1 of 1