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Home My WebLink AboutBLD-19-1360 'SI Jr:: .....r �.f - , .Permit" i. � . : qb . el^. PAmmmr �^'""�c� ?Permit expires 180 days from . issue date • $49-0— RA) --9-g2DI � . . EXPRESS BUILDING PERMIT APPLICATI IR E C E I V E TOWN OF YARMOUTH Yarmouth Building Department SEP 05 2018 1146 Route 28 South Yarmouth,MA 02664 BU ILDIr — (508) 398-2231 Ext. 1261 By: 1 pIc�1Lr la�rrI CONSTRUCTION ADDRESS: g-1 r Ne4o1i n,G to-ne,/ soi3OY-1, WillA-Q A-'71j ASSESSOR'S INFORMATION: • Map: 24 Parcel: / ( / OWNER: Toth /, (- -e-f P•o,Box 4571 SA hew sbvn, NAME PRESENT ADDRESS TEL # CONTRACTOR: CrA. V neewit /7Sh?/ 8vvoki?ol- S,$,vim ct,H'!, ?f4 2/2 -O'/3t3 NAME MAILING ADDRESS /esiTESL# dential 0 Commercial Est Cost of Construction S 0.3 d7lD Home Improvement Contractor Lic.# / 2.2 0a13 Construction Supervisor Lic.# eS95 , 3 2 Workman's Compensation Insurance: (sheik one) 0 I am the homeowner UI am the sole proprietor 0 I have Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy# WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares ( )Remove existing*(max.2 layers) Insulation Old Kings Highway/HistoriicDist. ( )Replacing like for like Pool fencing 1 ' 'The debris will be disposed of at "kat`r/' L t je- D I cp s al (a.eit0 oP jaakie.) 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 ocati//oo�n i�of//m}}''license and for prosecution under M.G.L Ch.268,Section 1. Applicant's Signature: Cr 4'7`"VX Date: arfrOF Owners Signature Date: Approved By: .../.." /" _ �•i Date: ��8 B; -:.g tial or desigue) LFMAII.ADDRESS: Zoning District Historical District 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: ' 0 Yes 0 No 0 Yes 0 No The Commonwealth ofMassaehusetts .1 42.... e&- —_ .t `]� , Department of Industrial Accidents • i ==10 1 Congress Street, Suite 100 = i= S Boston, Mel 02114-2017 %„—...... .4" www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information �� Please Print Legibly Name (Business/Organization/Individual): Cr A. VI�Cet-ti/1 /pica Address: 17- Shif a fro It go 4.4 • City/State/Zip: S.A.yI/t y/1 044 0Z664 Phone#: 1-14 -Zl 2 -(597 b Are you an employer?Check the appropriate box: Type of project(required): 1.0I a employer with employees(full and/or part-time).* 7. ❑New construction 2. am a sole proprietor or partnership and have no employees working for me in • any capacity.[No workers'comp.insurance required.] 8. Remodeling 3.❑I am a homeowner doing all work myself[No workers'comp.insurance required.]t 9. Demolition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property.ro I will 10 ❑Building addition errthat all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractor listed on the attached sheet These sub-contractors have employees and have workers'comp.instrance.r 13.❑Roof repairs 6.0 We are a corporation and its officers have exercised their right of=emotion per MGL c. 14.0 Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box El must also fill out the section below showing their workers'compensation policy information. I.Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractor 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 entitles have employes If the sub-contactors 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 MGL c. 152, §25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cerci under the painsandpenalties of perjury that the information provided above is true and correct Sis�Iaiure: (�17 VA vC& Date: 87 Z3l/g Phone#: f 94- 71')--09 3g Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): I. Board of Health 2.Building Department 3.City/Town CIerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: T J DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES In Witness Whereof,the parties have signed and sealed this Agreement in duplicate,each of which is deemed to be an original,on the day and year first above written. eitatiil iseAst Christopher A.Vincent •m Paquette,Owner President C.A.Vincent Inc. 8/18/18 112-2oLt. Date Date • • 17 STILL BROOK RD,S.YARMOUTH,MA 02664 1 PH:(774)212-0938 FAX(508)394-0550 I INFO@CAVINCENF.COM PAGE j6OF6 Fallon, Rosa From: Chris Vincent <christophervincent@comcast.net> Sent: Wednesday,September 5,2018 9:52 AM To: Fallon, Rosa Subject RE: CSL&HIC for C.A.Vincent We will be constructing a new garage addition, but wanted to get started on the demo. A separate application for the construction will be turned in later this week. Already have approvals for the construction from conservation and board of appeals. From: Fallon, Rosa [mailto:rfallon@yarmouth.ma.us] Sent: Wednesday, September 05, 2018 9:49 AM To: 'Chris Vincent' Subject: RE: CSL &HIC for C. A. Vincent Why is the garage being demoed? From: Chris Vincent[mailto:christophervincent@comcast.netj Sent:Wednesday,September 5,2018 9:48 AM To:Fallon, Rosa<rfallon@yarmouth.ma.us> Subject:CSL& HIC for C.A.Vincent Here are the copies of my licenses. Regards, Chris President,C.A. Vincent,Inc. C.A.VINCENT EMI DING S. IUMlU'!l ING Email: info@cavincent.com Website: www.cavincent.com Phone: 774-212-0938 ='' Virus-free.www.avg.com 1