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Home My WebLink AboutBLDX-25-1167 application e - 4;.yq (Mice Use Only. z p, r OH i :Amount '1• Qe/ EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTII Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 (5081398-223,11 Ext. 1261 CONSTRUCTION ADDRESS: a 9 �.. .,._ cl1#�e_b/c._o N s Y Q lccuf OWNER _ tj,j213.__..defe61 "=-R _ NAMI J/^ PRI Al NT 4D1)RL:At G /f/� TI-i,=�,y� p /�/^� Q CONTRACTOR -__6 �'l� 1 7S SV tl Z _ �/v" '-' 37P 310-f J l IS t NAMI \i kit INI;\DURESS TEL= EMAIL 7Cf//2 63.70re—$71O/LcC. C'itgCAT.NE7 / Sesidrnti.d :Commercial Est.Cost of Construction S /Se V,6 Homeowner is Applicant? \'es No Home Improvement Contractor Lic.# 7 TJ>� Construction Supervisor Lic.# Cis— V74 zSL7 WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate required) Wood Stove Siding: #of Squares A Replacement windows:# 7 Replacement doors: # I Roofing: #of Squares Insulation Temporary.Mobile Home Temporary Construction Trailer Demolition-Interior only __ 'Demolition Raze Structure Solar System ESS System Chimney. Fence -'I'lease submit utiln disconr/rttrCi letters lot elk.Irk&gas structures I,el''5s ears old require historical rev irw •The debris will he disposed of at. 61(4 �/• .5 'e"rr�� 1� Location of Facility I declare nil r penalties f pert a 'statemc herein contained are true and correct to the best ol'my knowledge and belief I understand that any false answertsl II be hist cause for denial of my- sec Lion under M.O.I.(h.26X.Section I.Applicant s Signat q r. Date. J �q—. Owners Signature for attachmenq . //Q t. (/ Date: 9 7 is" Appnrced Hy: Date: Building Official l or desioreeI Res bV The Commonwealth of Massachusetts Department of Industrial Accidents •1 Office of Investigations ~ Lafayette City Center wow / 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): � r,d/�,� )4stfiii Address: I'7s� c_�� 4k- £P. City/State/Zip: gi is Phone #: L-6_1c6l{ Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. VI I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑ New construction listed on the attached sheet. 7. ❑ Remodeling 2.❑ I am a sole proprietor or partner- 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 officers have exercised their 1 I.❑ Plumbing repairs or additions 3.El I am a homeowner doing all work 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' 13,11 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 D for insurance coverage verification. I do hereby ce u er the pains, Wes of peijury that the information provided tabove is true and correct. Signature6 vim' I Date: ! " `tc Phone#: 5c)> Zi b `r a ic1f 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): I❑Board of Health 21:1 Building Department 312City/Town Clerk 4.0 Electrical Inspector SElumbing Inspector 6.0Other Contact Person: Phone#: