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Home My WebLink AboutBLDX-26-504 RECEIVED ,f ! MAY 2 6 1016 PEt e Use Only unt "5Z> ICA AT.AEHEESE w ORPORAr EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-22231 Ext. 1261 CONSTRUCTION ADDRESS: C.2 DU/24 c I Gj�I /4,410,,,ii / l/► O2 73 OWNER: PseL(/Yl//S / �B �n �� hl�f i�i.44 k/�S1 1 G✓s�+✓ih �A o a‘73 (5-2,(4y7 NAME �f PRESENT ADDRESS / TEL. # 3off on- CONTRACTOR: NAME MAILING ADDRESS TEL.# EMAIL: _ 4f O/d,7 2fJ.iti/ 1eIw Residential ❑Commercial Est.Cost of Construction S ! 01,f/r Q� Homeowner is Applicant? Yes I/ No Home Improvement Contractor Lic.# Construction Supervisor 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 review *The debris will be disposed of at 01-/H (7 ��/MULJ� 4 0,) )-7/0 L ation of Facility 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 revocation of my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: t�/j Owners Signature(or attachment) .54 Date: ,�/!�/Z4 Approved By: Date: Building Official(or designee) Rev 6/24 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 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/Organization/Individual): SL"G, Nj&; / ( A/Die/7 Address: �Z r�l/1< f 24 1hr-A /f;4 02 173 City/State/Zip: Z.6 3 Phone#: y7 '3 0 �'3 Are you an employer? heck 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 2.0 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.t uired.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3. 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 employees. [No workers' 13.0 Other comp.insurance required.] *My 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. Iam 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 un er the aims and penalties of pesjuiy that the information provided above is true and correct Signature: Date: 6/ 6 Phone#: , bc'r e 1/7 3O,Y.5— 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 3EJCity/Town Clerk 4.❑Electrical Inspector 50Plumbing Inspector 6.0Other Contact Person: Phone#: Information and Instructions Massaot-rsetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Plirsuant'to this statute, an employee is defined as"...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as"an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships(LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you PP regarding the applicant. g b Please be sure to fill in thepermit/license number which wi ll be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in p pp any given year, need only submit one affidavit indicating current policy information (if necessary) and under"Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for o future permits or licenses. Anew affidavit must s be filled out each year. Where a home owner or citizen is obtaining a license or anybusiness not related to permit or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Lafayette City Center, 2 Avenue de Lafayette Boston, MA 02111-1750 Tel. (617) 727-4900 or 1-877-MASSAFE Revised 7-2019 Fax (617) 727-7749 www.mass.gov/dia