HomeMy WebLinkAboutBLD-25-1066 applicaiton O4. yA� Office Else Only
Z a p `-Permits
017$ Amount
EXPRESS BUILDING PERMIT APPLICATION X -lO
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth,MA 02664
(508)398-2231 Ext. 1261
CONSTRUCTION ADDRESS: 'fsC> A4 28
OWNER: I'tr-sP(11 t4e J /2 /. 114 2 8 / 70 ? b ?a 1 ✓
N,\Mt PRESENT ADDRESS TEL
CONTRACTOR:
\\\1t Al\ILI\l \DORF SS TI-L
EMAIL: -1—sssnIA4/Y',.sn,i1P4*'l4-t'�^^ -/
_Residential Commercial
Est.Cost of Construction S
Homeowner is Applicant? l'es No
Home Improvement Contractor Lic.# Construction Supen isor 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
*Please submit utility disconnect letters for electric&gas-structures over 75 years old require historical re%lew
'The debris will be disposed of at
Location of Facllits
1 declare under penalties of penury that the statements rein contained are true and correct to the best of my knowledge and belief I understand that any false answensl
will be just cause for denial or res.:anon fos-pw'onion under M.(i.L Ch.268.Section I.
Applicant's Signature Bate. g_.. j4/2,
Owners Signature(or achment) _ Date:
Appro,ed Hy-. Date:
Building Official tor designee)
Re,h 24
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
1 f/,' 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/OrganizationMdividual):
Address:
City/State/Zip: Phone #:
Are you an employer? Check the appropriate box: Type of project (required):
1.0 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
workingfor in capacity. employees and have workers'
me any
ca y comp. insurance.: 9. ❑ Building addition
[No workers' comp. insurance
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ 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 12.0 Roof repairs
insurance required.] t c. 152, §1(4),and we have no
employees. [No workers' 13.1: 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.
tContractors 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 above is true and correct.
Signature: Date:
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):
11:1Board of Health 20 Building Department 30City/Town Clerk 4.❑Electrical Inspector 50Plumbing
Inspector 6.0Other
Contact Person: Phone#: