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Home My WebLink AboutBLDX-25-973 f04;_ Office Use Only /.. 4\3 -'y `.Prnmtu 1.0 '�) 3 Id�... . Amount EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1 146 Route 28 South Yarmouth,MA 02664 (508)398-2231 Ext. 1261 CONSTRUCTION ADDRESS: t5 C 04A—CL-&z (A)Ct 5Yf i- Lei c.yA-g./1.10l PI' OWNER: Lt t gL\ C.1_t in elz S Cap(-0-W1- (.vILt5 kJ- 2(,t 5o k`13-)--) 6 0) \\\tl PRESENT ADDRESS TEL.a CONTRACTOR: \\\II SI AILING ADDRESS TEL.a EMAIL: LC.8C3lop tnMLTV. 'lei" ide / Resntial Commercial Est.Cost of Construction S 5-1 V O Homeowner is Applicant? l'es No Home Improvement Contractor Lic.# Construction Supervisor Lic.# WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate required) Wood Stove Siding: #of Squares 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 v *Please submit utility disconnect�letters for electric&gas-structures over 75 years old require historical review •The debris will be disposed of at: t1A(a�nin••O✓7'✓s 0I5po-c"- Location of Facility 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 answerls) Will be just cause lin denial err ocau�on of my license/cenn�rand for prosecution under M.G.L.Ch.26b.Section I. Applicant's Signature a v% /�/ Date. /r2 31R 5— Owners Owners Signature(or attacchh`me�nt)� /'/ / s./`� Date: I 3 I0�'.7 Approsed By: / Date _ Building Official t or designee) I Res 6 24 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations IMO mp Lafayette City Center - 1— ' 2 Avenue de Lafayette, Boston, MA 02111-1750 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers ).pplicant Information Please Print Legibly Name (Business/Organization/Individual): /LcLA 4 . / n cj 'e2 ddress: 5 (` °y, u/ ,( City/State/Zip: S c. '-1u Phone #: 5 u (;` —73 ) (, 6 Are 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 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. O Demolition working for me in any capacity. employees and have workers' co insurance.: 9. ❑ Building addition [No workers' comp. insurance comp. equired.] 5. O We are a corporation and its 10.0 Electrical repairs or additions 3. ILI I am a homeowner doing all work officers have exercised their 11.0 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 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 infonnation. 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 certifr under the pains and penalties of pedury that the information provided above is true and correct. Signature: /l/ --e-je Date: —7/ '/ a -7C Phone#: S GP- 7 - �' G 5 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): IOBoard of Health 20 Building Department 3.0City/Town Clerk 4.0 Electrical Inspector 5CIPlumbing Inspector 6.DOther Contact Person: Phone#: