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Home My WebLink AboutBLDX-25-1181- f O Y.i�.•� Office Use Only. <4 �'ol Permita)r-a-5- 1't ( 3 a ki Amount \rae "s/ `nor EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 (508)398-2231 Ext. 1261 CONSTRUCTION�ADDDRESS: J� // D �// r /r r (WNER: i/!t''r) l/7L4✓ O `` )GIPSs'1/(' /iK/W//r_' ,'---CV(J- jj 4?&- \AMI' PRISINI \1)11RI-SS TEL.x CONTRACTOR: NAMI. \L\ILI\t,\DDRI•SS TEL.. !! EMAIL: �j/2'7 G u 9 Q`/ ' (-"/.G ' residential Commercial Est.('Oct of Construction 13000 / ow Homener is Applicant? Yes V do Home Improsement Contractor Lic.k Construction Supenisor Lic.k WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate required) Wood Stove Siding: #of Squares // Replacement w indows:# Replacement doors: # Roofing: #of Squares �2( 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 reslew sd*The debris will be dispo of al. (fJ /elle/ � WGij(? "724r/��r Ql�f�,__ Location of Farilirs O/ I declare under penalties of peputy that the statements herein contained are true and correct to the best of my knowledge and belief. I understand that any fake answer(s) will be just cause fix denial or res of y license and tin prosecution under M.G.L.Ch.268,Section I..Applicants Signature' � Date:_.. �+!/2 S Owners Signature for attachment) /A �N� Date: g ji5 ) r Approsed By: Date: ___ Building Official for designee) Re:6 24 e . The Commonwealth of Massachusetts tt c Department of Industrial Accidents si iii'1 Es ' Office of Investigations Lafayette City Center — irr �...•I . 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: City/State/Zip: Phone#: _ 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 listed on the attached sheet. 7. ❑ Remodeling 2.El 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' t 9. ❑ Building addition [No workers' comp. insurance comp. insurance. 10.0Electrical repairs or additions required.] 5. ❑ We are a corporation and its eP 3.14 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 13.0 Other 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 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 p ' penalties of pedury that the information providedcorrect.above is true and Signature: 12�---- Date: A l 2 3 Phone#: J4li._.4"^ / ^^ 6-7 G 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 4.0 Electrical Inspector 5E lumbing Inspector 6.0Other Contact Person: Phone#: