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Home My WebLink AboutBld-19-007255 Y Office Use Only _ V. ',,. � ; -2Permit# f. A; O: t*.. C1 O �*'•' . H �Amount Permit expires 180 days from IIff�1J I(/V�/� ^ - ,issue date EXPRESS BUILDING PERMITL✓✓�✓✓/ APPLICATION TOWN OF YARMOUTH !U N p 1U�:i Yarmouth Building Department ( „)� 1146 Route 28 �(� South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 ,/ It CONSTRUCTION ADDRESS: 3( r�(Z c �_14Nb .R�, W f 1) i• /C y f `7CC (�J l� ASSESSOR'S INFORMATION: ./ Map: , Parcel: OWNER: , 'V�, `_ ,J ll LL J� 3ex)T1)c I �-�t�� (�.� -rig 236 C I i N PRESENT ADDRESS TEL..r# q / CONTRACTOR: ` /r 1 1 f/ O t k. ,�o� • '7/igS Cvt-, �v� T 3 d [ `I° I/ Al MAILING ADDRESS L c I(4. TEL.# Vi ❑Residential 'Commercial Est.Cost of Construction$ 3,Qw Home Improvement Contractor Lic.# f (3 �V , Construction Supervisor Lic.# C S c ir---V' I Workman's Compensation Insurance: (c one) ❑ I am the homeowner 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 1/ 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 7i1i9_Iti 1-�av rC e. ce Location of acility I declare under penalties of perjury that the statements herein contained are true and correct to the best of my knowledge and belief. I erstan at any false answer(s) will be just cause for denial "on e.if. or prosecution under M.G.L.Ch.268,Section 1. Applicant's Signatyg � (..i I Date: O< S / Owners Signature(or attachment) LL,lLlit- 5ec (. 2 .44. Date: -� 0C' ®� C 'ks 9 Approved By: . �� S Date: Building Official(or designee) EMAIL 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 of Massachusetts a Department oflndustrialAccidents tee' 1 Congress Street, Suite 100 _f:l�f Boston, MA 02114-2017 • www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information //JJ PIease Print Legibly Name (Business/Organization/Individual): `/(/( t r ( CL I N Address: �s �"" �.�.�, C City/State/Zip:_(904 C. 3 Phone #: J O Are you an employer?Check the appropriate box: Type of project(required): 1.❑I am a e er 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 8. ❑ e ng any capacity.[No workers'comp.insurance required.] 3. I am a homeowner doing all work myself 9. ❑ Demolition ❑ y [No workers'comp.insurance required.]` 10 ❑ Building addition 4.11 I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that 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.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp. insurance.: 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(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. 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 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 certify e the ai ties of perjury that the information provided ab ye is true and correct Signature: ►'� Date: 172AY ? Phone#: S 0�' 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#: r'�4" 91/Ilierlect'eala(/)(2747ah¢44ttJe Office of Consumer Affairs&Elusines (# HOME IMPROVEMENT CONT 11 TYPE:IndMdu v% t�atf :. MICHAEL J.DINO►A • MICHAEL J.DINOIA 32 OUTPOST LN • CENTERVILLE,MA men Undeitecre#ary ,ornnonwealth of Massachusetts Division of Professional f_icensure 1, Board of Building Regulations and Standards r ConstroCtionb ' _ . z` • . CS-05$441 a �ires: 10,15/2019 MICHAEL J DINOIA 32 OUTPOST CM %+ CENTERVILLE MA 02632 \ • );-‘0, Commissioner :Regulation-Mass.Gov-Internet Explorer ma.us hic%licenseelist.aspx " Search... aelc 4,143 L aitfrivacy ■ >2 Business Housing a . . „ Regulatien (OCABR) Home Improvement Contractor Registration Lookup To search by registration number,enter the registration number in the textbox below and click the'Search'button. Please note pressing the Enter key will clear fields. Search by Registration Number 113239 Search You must click the"Search Registrant"button to search by name or location. Please note pressing the Enter key will clear fields. Search by Registrant Company name Search Registrant Search by Registrant Last name City/Town State Zip code Click on the registration number to view complaint history.You can also view arbitration and Guaranty Fund history The list is current as of Monday,June 24,2019. Search Results RegistrantName RESPONSIBLE REGISTRATION ADDRESS EXPIRATION DATE STATUS INDIVIDUAL NUMBER MICHAEL J. DINOIA DINOIA,MICHAEL 113239 32 OUTPOST LN 05/26/2021 Current CENTERVILLE,MA 02632 Site Policies Contact Us 8 2018 Commonwealth of Massachusetts. Mass.Gov®is a registered service mark of the Commonwealth of Massachusetts. ,/Trusted sift a [❑le % -: