HomeMy WebLinkAboutBLDX-26-325 RECEIVED , Office Use Only
';y' APR 15 2026 Amount
9 '
\�QoePORA�Eo�'' BUILDING DEPARTMENT
By. _ ..__.
EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664
�j (508) 398-2231 Ext. 1261
a/CONSTRUCTION ADDRESS: '► 96 &' /0&IdOO O
OWNER: ` es \QY'. &J Calkio v, W k `c s c<O \ 5°2 3 `O LI 3 6 -0
NAME PRESENT ADDRESS TEL. #
CONTRACTOR:
NAME MAILING ADDRESS TEL.#
EMAIL: I '( \en, ( e\VVC)Q hp-k rrtqj c-OrY-1 ,
Li co 0
Residential ❑Commercial Est.Cost of Construction$
Homeowner is Applicant?41.
No
Home Improvement Contractor Lic.# Construction Supervisor Lic.#
WORK TO BE PERFORMED
Tent Duration (Fire Retardant Certificate required) Wood Stove
Siding: #of Squares 33 S.(.- 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
s.
*The debris will be disposed of at: ,..,"1 l' C)V O V
'C (_C .
` Location ofacuity
I declare under penalties of perjury 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 or revoc tion of my license and for prosecution under M.G.L.Ch.268,Section 1.
,"------- YiApplicant's Signature: Date: 0 /5 0914 4'
Owners Signature(or attachment) IQy1_1420 (L V\----.:--) Date:
Approved By: Date:
Building Official(or designee)
Rev 6/24
The Commonwealth of Massachusetts
Department of Industrial Accidents
— Office of Investigations' Lafayette City Center
=om 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): Q(ylc_10.AO
Address:1 j ,,- 1a.Q UJ c� w c.)o w•
City/State/Zip-�J• 7c\ alac'V Cf'\1\ Phone#: S c 3€' O
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. El 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'
[No workers'comp.insurance comp.insurance.: 9. Building addition
required.] 5.❑ We are a corporation and its 10.0 Electrical repairs or additions
officers have exercised their 11.❑Plumbing repairs or additions 3. ,I am a homeowner doing all work
myself.[No workers'comp. right of exemption per MGL
Ys P 12.❑Roof repairs
insurance required.]t c.152,§1(4),and we have no 13.®Other m oJC
employees.[No workers'
comp.insurance required.] 9\Q pA. w'
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. -1
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 pains and
((penalties of perjury that the information provided above is true and correct
Signature: t'./11,-L�;_„ l-,C7t Date: (i I I SI02'''db
Phone#: 5c� 3 G I <S61
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:City/Town Clerk 4.0 Electrical Inspector 5.EIPlumbing
Inspector 6.0Other
Contact Person: Phone#: