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HomeMy WebLinkAboutBld-20-001512 g Office Use Only 4.1 $• ; %I 4 Permit# ? 14J Amount ._.. t '� nwri� n es ��(-2-- � , Permit expires 180 days from : ;_:::..• � Zr issue date EXPRESS BUILDING PERMIT APPLICAtION(~• TOWN OF YARMOUTH Yarmouth Building Department . SE' 17 2O1I 1146 Route 28 South Yarmouth, MA 02664 ; CAS (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 70 ey 4 t val./?,t,tee-44....a ASSESSOR'S INFORMATION: Map: Parcel: -'.4/2 >1-eWNER: /?á A j'O R k A ��� /L / sv 7�C7 ` 2�'�S-1 NAME RESENT ADDRESSY TEL. # CONTRACTOR: mod`" =e I� ii i °" ;"✓1'J 9� NAMEME MAILIN ADDRESS TEL.# ,Residential 0 Commercial Est.Cost of Construction$ 5' 6 / Home Improvement Contractor Lic.# 1$3 7 / Construction Supervisor Lic.# Z C.,-7 f O 7 Workman's Compensation Insurance: (check one) ❑ I am the homeowner )ClJ am the sole proprietor ❑ I have Worker's Compensation Insurance Insurance Company Name: 7 --c.-4, Worker's Comp.Policy# L(/c C- 5cid Sal g'e7101 P WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares ) Replacement windows:# Replacement doors: # Roofing: #of Squares (ii(�1/ (,'C)Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: il o DW 'Locati of F ili I declare under penalties of 'ury 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 de o ocatio of my ' d f prosecui,'+un r M.G.L.Ch.268,Section 1. //‘/( Applicant's Signature: si' Date: Owners Signattt5 a(or attachment Date: CT l/C-4f Approved By: ��-..-l�,.,, Date: / -l) "t 5 Building Official(or designee) ''EMAIL ADDRESS: Zoning District: Historical District: 0 Yes ❑ No Flood Plain Zone: 0 Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No ' • The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street, Suite 100 _ �- Boston, MA 02114-2017 ' www.mass.gov/dig Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organiaation/Individuap: Address: o �q °(,. 1� L ' PO City/State/Zip: Phone #: SO-g 3 Z `fs� Are you an employer?Check th appropriate box: Type of project(required): 1.❑I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.Z.am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling any capacity. [No workers'comp.insurance required.] 3. I am a homeowner doing all work myself. 9. ❑ Demolition ❑ y [No workers'comp. insurance required.] 4.❑I am a homeowner and will be hiring contractors to conduct all work on mYproperty. I will 10 ❑ Building addition 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. These sub-contractors have employees and have workers'comp. insurance.: 13.❑Roof repairs 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. c5 S c(gS e` ' via Expiration Date: GP-1(34> (p. Job Site Address: a '7 � C-- City/State/Zip: Attach a copy of the workers' comi'ea'ation policy declaration page(showing the policy nu ber and expiration n 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 under pains and penalties of perjury that the information provided above is true and correct. Signature: Date: ( t4 - l Phone*: 01 3 79 5 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#: e -viv,-/o/rt<<eaClic`y .. Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Corporation Registration Expiration 1.53792 01/07/2021 C&F REMODELING CARLOS H.FIGUEIROA 20 CAPTAIN NOYES RD_ S.YARMOUTH,MA 02604 Undersecreta • Commonwealth of Massachusetts Division of Professional Licensure Board of Building Rulations and Standards Const #egn'S p?rv'•sor CS-104107 x = !pires: 08/25/2019 :,CARLOS H FIGUEIROA jr. 20 CAPTAIN NOYES RAY SOUTH YARMOI�.TH M '0266 Commissioner corn,'erf_aticm- tad.a __ ... �_pr.`reuS=6a L3 3_,,. c a,.i-aec cl__1'_67a_2r _.... ... .._." C% Search... )etails The Official Website of the Executive Office of EOHED and Divs,on of Professional Licensure weir ; Public Safety - .. H�„e Srat=A.cen,s , Mass. Licensee Details Demographic Information Full Name: CARLOS H FIGUEIROA Owner Name: License Address Information City: South Yarmouth State: MA Zipcode: 02664 Country: United States License Information License No: CS-104107 License Type: Construction Supervisor Profession: Building Licenses Date of Last Renewal: 8/9/2019 Issue Date: 5/20/2010 Expiration Date: 8/25/2021 License Status: Active Today's Date: 9/17/2019 Secondary License Type: Doing Business As: Status Chanqe Reason: License Renewal Prerequisite Information No Prerequisite Information No Available Documents Close Window I ©2011 Commonwealth of Massachusetts Site Poliaes Contact Us ®Intern o t e E H ') oa