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Home My WebLink AboutBLD-19-001745 rot „Au,`r T 1, G L 3 Gay / it �� SEP 24 2018 ;.Amount hJ --�%**.t0o d'd'' Petmit expires 180 _ _ issue daze days from 9 LC .�EPM _ EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: /r 'fwO°Hrt.P/i �zeeE-� Yea V'°'L'”"`L! ASSESSOR'S INFORMATION: Map: Parcel: OWNER: 131It. L A-0.,Y it1u 2-c YI^sLAiv A-utMr Wo(fw -I 7e/ 177- lei?7 NAME PRESENT ADDRESS TEL # CONTRACTOR: «-oLI- A4r.s-gtw'M, 23 wtn-47', 4 -, - (Noown r '7E/ cn- 2f:f—Z/ NAME MAILING ADDRESS TEL it Nai sidential 0 Commercial . Est Cost of Construction$ QUO /1-3Z - . — s, H Home Improvement Contractor Lic.# (7�2 7�o Construction Supervisor Lie.# C S o7�fJ Z Workman's Compensation Insurance: (check one) ' 0 I am the homeowner ❑ I am the sole proprietor ser 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 EpeeReplacement windows:# Replacement doors: # Roofing: #of Squares ( e ( move existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist ( )Replacing like for like Pool fencing 'The debris will be disposed of at S 4- v e xC W Location of Facility I declare under penalties of perjury that . .1 meats herein contained are true and correct to the best of my knowledge and belief [understand that any false answer(s) will be just cansr d r revocatio, of.. license and for prosecution under Mat.Cb.268,Section 1. p Applicant's Signature. Date. / , l e1-7L/c 5= Zif-Zo/6' Owners Signature(or attachment , A 6. Date: Approved By: �1 /' Date: 9.02 9729 din' ci• or designee) • a CRESS: Zoning District . Historical District ❑ Yes 0 No Flood Plain Zone: ❑ Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: ' 0 Yes 0 No 0 Yes 0 No .sr,,..? . The Commonwealth ofMassadhusetts 114 a, ,, _�/ Department of Industrial Accidents c _ �1= 1 Congress Street,Suite 100 _ �= Boston, MA 02114-2017 ' .,.4 www.tru2ss.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): PA U-L t S Lk- ngenev' SE-twat Ll .6.4_ �,/g , r o- Address: 9/ 7 run c." Sr- /try 36 City/State/Zip:U )-EL,N.zui,,, 1j Win Phone#: 7e/ eye/ - 7520 Are you a employer?Check the appropriate box: �L Type of project(required): I. I am a employer with-r /t C'imployees(full and/or part-time).* 7. ❑New construction 2.0 I am a sole proprietor partnership and have no employees working for me in 8. ❑Remodeling • any capacity.(No workers'comp.insurance required.] 3.0 I am a homeowner roma all work myself9. ❑Demolition (No workers'comp.insurance required.]t 4.❑I am a homeowner and will be hiring contactors to conduct all work on my property.ro I will 10 ❑ Building addition ensure that all contactors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.0 1 am a general contractor and I have hired the sub-contractors listed on the attached sheet These sub-contractors have employees and have workers'comp. insurance.: 1.3. oof repairs 6.0 We are a corporation and its officers have exercised their right14.❑Other 152,41(4),and we have no employees. insuranceanctptien per MOL c: [No workers'comp, required] *Any applicant that ehecla box#1 must also fill out the section below showing then 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-contactors and state whether ar not those entities have employees. If the sub-contractors have employees,they must provide thea 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: Pari-find 1)t/Le..... t N s Co. Policy#or Self-ins.Lic.#: O 8 Cu C' cc L. 77 7 ?Expiration Date: f/a/ /2 0/ 9 Job Site Address: 15—SLvi„o r`r?t/ at,104 ' City/State/Zip:f 5444.4•••14 #z'd Olay 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 hereb rider . e pal, and penalties of perjury duo the information provided above is true and correct Sisnature: e��` Date: Frit! -(P. Phone#: 7&I 6NN - 25-fro 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. CityiTown Clerk 4.Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: Office of Consumer Affairs & Business Regulation-Mass.Gov Page 1 of 2 it Mass.gov Office of Consumer Affairs and Business Regulation (OCABR) HIC Registration Complaints Registration # 130278 Registrant PAUL'S LANDSCAPING SERVICE & SUPPLIES, LTD Name ROBERT AUTENZIO Address 23 MILAN AVE. City, State Zip NORTH WOBURN, MA 01801 Expiration Date 02/10/2020 Complaints Details No complaints found for this registrant. You can also view arbitration and Guaranty Fund history. Back To Search Site Policies Contact Us https://services.oca.state.ma.us/hic/licdetails.aspx?txtSearchLN=130278 9/24/2018