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Description 110 WI y rf� t-' Li /— U Unrestricted(Buildings up to 35,000 cu.ft.) w �� / tR Restricted l&2 Family Dwelling City/Town,State,ZIP M Masonry . • RC Roofing Covering WS Window and Siding �/'/ !� �• 9 SF Solid Fuel Burning Appliances ✓6 f 3©6 g`g g I Insulation Telephone Email address D Demolition . 5.2 Registered Home ImprovementprContractor(HIC) 492 9 p . ®�' Y 3 2020 r^A aL ! 4`v/#('r5 HIC Registration q' 14gistration Number Expiration Date HIc het N I roc�or Regisr n� N�f R4 nt.Name pliy4/Y-5 seo,PI (GAG, e7 egipefehz /-(ici- 026V) 56/'306'1'253 Email address City/Town,State,ZIP Telephone SECTION 6:WORKERS' COMPENSATION INSURANCE AFPIDAVIT(M.G.L c.152.§ 25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuance of the building permit. Signed Affidavit Attached? Yes 0 No...........@! SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT .. I,as Owner of the subject property,hereby authorize to act on my behalf,in all matters relative to work authorized by this building permit application. J `y, I- 11-2 q- 1 t Print Owner's Name(Electronic Signature) Date • • SECTION 7b: OWNER'.OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information cants',-. in this application is true and accurate to the best of my lmowledge and understanding. , /L. o;. /d' '(--Print a er's or Authorized Agent's Name(Electronic Signature) • Date . NOTES: • _ 1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L.c. 142k Other important information on the HIC Program can be found at www.mass.eov/oca Information on the Construction Supervisor License can be found at www.mass.cov/dos 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch) Gross living area(sq.ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" The Commonwealth of Massachusetts - Department oflndustrialAccidents sE111i- 1 Congress Street, Suite 100 • -1! Boston, MA 02119-2017 . �,�_ • www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Leaiblx Name (Business/Organization/Individual): f\y3\4 G 9 110/VE 1/7/W.©aatietr _ Address: 2E, 4j1/4 i City/State/Zip: I/AP W/M / /14 026V6 Phone#: 56 t" 306 S'23 e Are you an employer?Check the appropriate box: - Type of project(required): LQ I am a employer with employees(full and/or part-time).• 7. 0 New construction 2.IR13.1 am a sole proprietor or partnership and have no employees working for me in any capacity.[No workers'comp.insurance required.] 8• Remodeling 3.0 I am a homeowner doing all work myself.[No workers'comp. insurance required.]r 9. 0 Demolition 4.0 I am a homeowner and will be hiring contractors to conduct all work on m Yproperty. 1 will 10 9 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical Iepairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.01 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.? - 13.❑Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.0 Other 152,§I(4),and we have no 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.Lie.#: 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 a. 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$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 do hereby certify.er the pains and penalties of perjury that the information provided above is true and correct Signature: pp Date: /( J 1671 Phone#: r /3 R2_ rq Official use only. Do not write in this area,to be completed by city or town officiaL City or Town: Permit/License# • Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: • • .01 ritclitTOWN OF YARMOUTH • * c BUILDING DEPARTMENT Ter ;-•:,c,„ ,�$ 1146 Route 28, South Yarmouth,MA 02664 508-398-2231 ext. 1261 HOMEOWNER LICENSE EXEMPTION PLEASE PRINT: DATE: JOB LOCATION: • NAME STREET ADDRESS SECTION OF TOWN "HOMEOWNER" NAME HOME PHONE WORK PHONE PRESENT MAILING ADDRESS CITY OR TOWN STATE ZIP CODE The current exemption for 'Homeowner' was extended to include owner—occupied dwellings of one or two units and to allow such homeowners to engage an individual for hire who does not possess a license,provided that such homeowner shall act as supervisor. (State Building Code Section 110 R.5.1.3.1) Definition of Homeowner: Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is or is intended to be, a one or two family attached or detached structure assessor),to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner;such"homeowner"shall submit to the building official,on a form acceptable to the building official,that he/she shall be responsible for all such work performed under the building permit. (Section 110 85.1.3.1) The undersigned 'homeowner' assumes responsibility for compliance with the State Building Code and other applicable codes,by-laws,rules and regulations. The undersigned 'homeowner' certifies that he/ she understands the Town of Yarmouth Building Department minimum inspection procedures and requirements and that he / she will comply with said procedures and requirements. HOMEOWNER"S SIGNATURE APPROVAL OF BUILDING OFFICIAL INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent, which meets the requirements of MGL Ch.142. Yes No If you have checked yes, please indicate the type coverage by checking the appropriate box. A liability insurance policy Other type of indemnity Bond OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner Agent h:homeownrlicexemp y, .Z.b�•YA\o TOWN OF YARMOUTH •yg c BUILDING DEPARTMENT o• 'en = /; 1146 Route 23,South Yarmouth,MA 02664 �, s 508-398-2231 ext. 1261 Fax 508-398-0836 BUILDING DEPARTMENT DEMOLITION DEBRIS DISPOSAL AFFIDAVIT Pursuant to M.G.L Chapter 40,Section 54 and 780 CMR, Chapter 1, Section 1115, I hereby certify that the debt-is resulting from the proposed work/demolition to be conducted at 83 (1477-4C kEF RA S Y8Ruovrii n''¢ Work Address Is to be disposed of at the following location: Cy/ie (5 Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. Signatu of Application Date Permit No. • rowzma / /94a Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement.Contractor Registration Type: Individual '9 Registration: 192964 GABRIEL PANAITE T + Expiration: 08/30/2020 D/B/A G&R HOME IMPROVEMENT _ +___ r. 862 QUEEN ANNE RD HARWICH,MA 02645 — Update Address and Return Card. SCA 1 0 2,011--05/17 re17 / nzene Brea/�!e.£G¢-3Jzf/t2se/l' ._. .. _ Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Individual before the expiration date. If found return to: Registration. Expiration Office of Consumer Affairs and Business Regulation X92964:=_ - 08/302020 1000 Washington Street-Suite 710 GABRIEL PANAITE Boston,MA 02 D/B/A G8R HOME IMPROVEMENT GABRIEL PANAITE f'/� 862QUEEN ANNE RD[ � �/, HARWICH,MA 02645 - Undersecretary- jot valid ut signature • • Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Constrylct1&1i$up,rvisor CS-112592 / r'qE E pires: 01/0512022 f GABRIELI PANAITE t;.) y QUEEN 862 ANNE ROAD .; ` - 862HAR MA 0 645., � ! (:nmmissinner Com- TOWN OF YARMOUTH _ __ -_ ' REVIEWED FOR BUILDING AND ZONING CODE COMPLI- ANCE ERRORS OR OMMISSIONS DO NOT RELIEVE THE APPLICANT FROM THE RESPONSIBILITY OF'AS BUILT' COMPLIANCE. DATE: I *J K'ITJ� B ILDIN ICTAL I al �2 m APP 50:1P5-64-7— ` -- _ •ZL5A.tA.?Arta_ ____ ZX4u 7111. ?sat)_ca____-_ G2i!Lt'JJIl lelr rt + • I =IMI . is 4I FILE COPY . ct MICHELE ac, i 4 CUDILO A sSTRUCTURAL m No 34774 G ISSION AI ' RESIDENCE MODIFICATIONS MICHELE C DILO, P.E. # 21/. . Consulting' Structural Engineer . , Centerville, Massachusetts 02632-1979 (508)771-7601 83 MATTACHEE RD. Drawn By: MC Date: 11/21/18 Drawing So. Yarmouth, MA Scale:/�ds NOTED Rev.' 0 SK- 2 File Name:G&RIMPROV Project No.2018-342