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Home My WebLink AboutBLDX-26-866 applicaiton !9 yA t g Office Use Only /01 r, :'� ' ' ;tW12j�� 1 Permit# a(te ( , z s€i. ity tt0� -0/y' \ Amount 1 Z) ir la XPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: ,9 . c.ii. yr, OWNER: ft/.A4t.P 0 #�j� "" 'y 503^9 Y —6crye N E PRESENT 1DRESS TEL. # CONTRACTOR: KNAME MAILING ADDRESS TEL.# Lci. crao ao/. CoM EMAIL: fit Residential ❑Commercial Est.Cost of Construction$ 6/ 0,Pf 0 Homeowner is Applicant? Yes a 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: # 1 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:_ Location 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: l(/ /, ,o Date: -�77 �J Owners Signature(or attachment) ItiletC1r1('j L') A /Date: -3I ii 6 Approved By: Date: Building Official(or designee) Rev 6/24 The Commonwealth of Massachusetts - Department of Industrial Accidents Office of Investigations `0�— Lafayette City Center tt•'lltfr 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: 3 �vd, /.?'ep, 0tab75" City/State/Zip: Phone#: Are you an employer?Check the appropriate box: 4. Type of project(required): 1.❑ I am aeneral contractor and I Iamaemployerwith ❑ g employees(full and/or part-time).* have hired the sub-contractors 6. 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 3.0 I am a homeowner doingall 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' 13.1M Other G...lb,,d 4 2,pyl7 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 pains and penalties ofperjury that the information provided above is true and correct Signature: / 6? fA2,4 Date: 7--3, Phone#: �✓Ef—9 i't "-(r r1'yet 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 30City/Town Clerk 4.0 Electrical Inspector 5Elumbing Inspector 6.0Other Contact Person: Phone#: