The URL can be used to link to this page

Home My WebLink AboutBLD-19-001825 • y Og•y ;Office Use Only • t+ ''�0. .Permit# C py. 'Amount cJ LI N r 4' I `►r•• sro, Permit expires 180 days from issue date L31A—M b iAas EXPRESS BUILDING PERMIT APPLICA . R C E I V E D TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 SEP 26 2018 South Yarmouth,MA 02664 (508)398-2231 Ext. 1261 But By. S. CONSTRUCTION ADDRESS: 19 Town Hall Avenue ASSESSOR'S INFORMATION: Map: 059 Parcel: 8591 OWNER: Brian Osborne 102 Constance Avenue.West Yarmouth.MA 02673 NAME PRESENT ADDRESS TEL # CONTRACTOR: Stello Construction Enterprises,Inc. P.O.Box 776,South Chatham, MA 02659 508-432-2218 NAME MAILING ADDRESS TEL# ®Residential 0 Commercial Est.Cost of Construction$ $1,750.00 Home Improvement Contractor Lia# 192090 Construction Supervisor Lic.It 015649 Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 1 am the sole proprietor 2 I have Worker's Compensation Insurance Insurance CompanyName: Zurich American Worker's Comp.Policy# 6ZZUB-921X274-4-02 WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares 2.5 Replacement windows:# Replacement doors: # Roofing: #of Squares ( )Remove existing*(max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing 'The debris will be disposed of at: S&J Exco,South Dennis,MA Location of Facility I declare under penalties of•erjury that the statements he n 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 de lip vocation of m li e a r prosecution under M G L Ch.268,Section 1. �• 9'7t/a 5' /7 Applicant's Signature: � Y,C/� Date: �t �' f, Owners Signature(or attachment de gnee) (,�/ Date.9�/r� I/ 1( Approved By: .,, //6� yy Date: _ •-- j4� 76 ng O - ial(or de gnee) EMAIL RES-S: Zoning District: R40 Historical District: ❑ Yes 3 No Flood Plain Zone: 0 Yes 3 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 1)1 No ❑ Yes 3 No ✓. The Commonwealth of Massachusetts Department of Industrial Accidents r►__ II=Ei Office of Investigations iilfl_ ' 600 Washington Street Se=? Boston,MA 02111 :y — t, .a_i' www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly • Name(Business/Organization/Individual): Stello Construction Enterprises, Inc. Address: P.O. Box 776 City/State/Zip: South Chatham, MA 02659 Phone#: 508-432-2218 Are you an employer? Check the appropriate box: Type of project(required): 1.❑X I am a employer with 10 4. ® I am a general contractor and I 6. 0 New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet.: 7• 0 Remodeling ship and have no employees These sub-contractors have 8. 0 Demolition working for me in any capacity. workers'comp.insurance. 9. 0 Building addition [No workers'comp.insurance 5. 0 We area corporation and its officers have exercised their 10.0 Electrical repairs or additions required.] o 3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself.[No workers'comp. c. 152,§I(4),and we have no 12.0 Roof repairs insurance required.]1 employees.[No workers' 13.0 Other 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 their workers'comp.policy information. t am an employer that is providing workers'compensation insurance for my employees. Below is the policy and Job site information. Insurance Company Name: Zurich American Policy#or Self-ins.Lic.#: 6ZZUB-921X274-4-02 Expiration Date: 09/01/2019 Job Site Address: 12 Town Hall Avenue City/State/Zip: South Yarmouth, MA 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 c I y under th 'ns tr penalties of perjury that the information provided above Is true and correct. Signature: \,....„... Date: l ia ,�� Phone#: 508432-2218 Official use only. Do not write in this area,to be completed by city or town ofjiciai City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: r. \. cZ?P iCO)N)Ntnweaf/A(/n/(O.tlafAeapo Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Canoration pealstration Expiration 192090 06/07/2020 STELLO CONSTRUCTION ENTERPRISES,INC ROBERT K.STELLO , 310 COMMERCE PARKN U� SOUTH CHATHAM,MA 02659 Undersecretary ! C. Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards ConstructiOrt BtSpervisor Cs-015649Expires: 06/09/2020 Zj ROBERT K STELLO ^! ! • tf PO BOX 776 rr� SOUTH CHATHAM MA 02659 1-1 -c - . Commissioner A