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Home My WebLink AboutBLDX-25-1478 / 1 At_ Office Use Only : f 1440.4\ Permit# l __F_: x . i Amount 50 a)Y: �s�q* ORPORoso,i,- EXPRESS BUILDING PERMIT APPLICATI N TOWN OF YARMOUTH RECEIVED __ Yarmouth Building Department 1146 Route 28 NOV 0 32025 South Yarmouth,MA 02664 (508)398-2231 Ext. 1261 BU I I 1 - T NT /� By CONSTRUCTION ADDRESS: /CQQ �1 o rC. 'c V`-aZ, OWNER: S i yil 4,ii, /1' 4,- . `T 4f. l N P� l PRESENT S3 ''Cf.l\aN ao TEL. �- CONTRACTOR: ); f( NAME MAILING ADDRESS TEL# EMAIL: 1,�/4 c G er 42 s4¢szia.Ga4 but nC h i 2(]�'.,�-2T 1— (-7 Co 5 kr"-C l i ' C )61 �.. ❑Residential ❑Commercial ❑Est Cost of Construction S / Coe) Homeowner is Applicant? Yes )( No Home Improvement Contractor lic# /'/4 Construction Supervisor Ix.# Al/ 14 WORK TO BE PERFORMED n. Tent Duration (Fire Retardant Certificate required) Wood Stove Siding: #of Squares 9 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 review *The debris will be disposed of at r/', ,�j y r-;•b ..iriA /I/. . Asa Location of Facility I declare under penalties of - that the statements herein contained are true and correct to the best of my knowledge and belief I understand that any false answer(s) will be just cause for denial revocation of my license and prosecution under .G.L.Cyr.268,Section 1. Applicant's Signature. \\ 1 (3 Dane: 11.,3 ` t9 ea Owners Signature(or athairrrent) Date:))• ' a�� If=, v Approved By: IL/1 Building Official(or designee) Rev 6/24 The Commonwealth of Massachusetts ,,_„,;- Department of Industrial Accidents t Office of Investigations Lafayette City Center %'� 2 Avenue de Lafayette, Boston, MA 02111-1750 M �� www.mass gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information `, Please Print Legibly ame(Businessioruanization/lndivid ce�nat): ��.,,.j�' 1_y e2 4 Address: /D av.� ,A , L.rth? 7 City/State/Zip: hone#: g6j• 4'J• / g62 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. 0 Remodeling ship and have no employees These sub-contractors have g. ❑Demolition workingfor me in anycapacity. employees and have workers' P h # 9. ID Building addition [No workers' comp.insurance comp.insurance. required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3.qI 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.] ' c. 152,§1(4),and we have no employees. [No workers' 13.0 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 sate 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 cerkfy under the pains and penalties o perjury that the information provided above is true and correct Si ture. Date: Phone#: 0 • / /) • / Q p? 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 20 Building Department 31:1City/Town Clerk 4.0 Electrical Inspector 5alumbing Inspector 6.DOther Contact Person: Phone#: gY TOWN OF YARMOUTH r.` 0 if, x Office of the Building Commissioner Y - - - 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260 Fax 508-398-0836 DEMOLITION DEBRIS DISPOSAL APPLICATION Pursuant to M.G.L. c.40 §54 and 780 CIVMR Section 105.3.1 #4.. I hereby certify that the debris resulting from the proposed work/demolition to be conducted at. Jo y�{�� ,/ L $'. y,4r Q0 mil, Work Address Is to be disposed of at the following location,/ a 4- /41 rye <0 -4 Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, §150A. r" 1 • R- i ature A p ' nt Date Lfi 47 to is D 03 Permit No.