HomeMy WebLinkAboutBLDX-26-685 applicaiton j'Og, y`9�\\ RECEIVED
E C E I V E D Office Use Only
tZ 476\. r' G ._._.. Permit#X-ace` co
JUN252026
4 O - . i 1 Amount �r—
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s„zol ATE°/,/ ' BUILDING DEPARTMENT I
By.
EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1 146 Route 28
South Yarmouth, MA 02664
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(508 8-2231 Ext. 126:Speyb
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CONSTRUCTION ADDRESS: Y4t.Thd,j47
OWNER: 0-4,44J fAll&b•&( 77 ''' 7-GZ iO
NAME� PR S T ADDRESS TEL � 07ca
CONTRACTOR: ?7 '(
NAME MAILING ADDRESS TEL.#
EMAIL: L _ (' C9n/
residential ❑Commercial Est.Cost of Construction$ '� CVO
Homeowner is Applicant? Yes bNo
Home Improvement Contractor Lic.# Construction Supervisor Lic.#
WORK TO BE PERFORMED
Tent Duration (Fire Retardant Certificate required) Wood Stove
Siding: #of Squares 3 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
54.1004641
*The debris will be disposed of at: Mi i'✓'
o on of Facility
l declare under penalties of perjury that e 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 ocation o y license for ecution u r M.G.L.C .268,Section I. /
Applicant's Signature: Date: 475
Owners Signature a ent) {p Date: z 6
Approved By: _ _ _ _ _ Date:
Building Official(or designee)
Rev 6/24
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The Commonwealth of Massachusetts
Department of Industrial Accidents
•e = 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 I Q��/� Please Print Legibly
Name(Business/Organization/Individual):r/ j0—fiat/. Lit ��`r�V .
Address:
City/State/Zip: - l i'`->7 &/141 Phone#: f•-7 j ±1 CJ 7 c
Are you an employer?Chec the appropriate box: Type of project(required):
1.El 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. ❑Remodeling
ship and have no employees These sub-contractors have g. r1 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
3.❑ I 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.❑Roof repairs
insurance required.]t c.152,§1(4),and we have no 13.❑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 / r the p ' s and penalties of perjury that the information provided above is ue and correct.
Signature: / / Date: V/G(..-
Phone#: ) !
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):
1❑Board of Health 21:Building Department 3❑City/Town Clerk 411 Electrical Inspector SD'lumbing
Inspector 6.❑Other
Contact Person:_ Phone#:
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