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Home My WebLink AboutBld-20-001535 ,.Y Office Use Only Permit# f '171 ' . ff Amount w�Tr' n s r � ��' 6�d' l i Permit expires 180 days from t :: .�, : • O(A)�J10 I issue date. `.. EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH SEP 18 2U1h Yarmouth Building Department 1146 Route 28 Cell' South Yarmouth, MA 02664 /((55088) 398-2231-2j� Ext. 1261 CONSTRUCTION ADDRESS: C�i 4f " �%%"° '�j 144112- Yolt1/0/04WP 4 /4 lly, ASSESSOR'S INFORMATION: Map: Parcel:rc /� c / OWNER: /r� � �� 'j�; 40 4 �7 �f/�/�J� C��1}774 , NAME PRESENT ADD SS TE/ r} �j [/D7[/ CONTRACTOR: ( RAD s t�4.f• C.N Z 4 At N wli-5 2� S Q9 d 3 /, 59 J -NAME MAILING AD S TEL.# r Residential 0 Commercial Est.Cost of Construction$ 1 - 0 0CJ-- cO Home Improvement Contractor Lic.# 1 53 ' _nn 6.)-- Construction Supervisor Lic.# 1 O"t J 0 Workman's Compensation Insurance: (check one) I am the homeowner G I am the sole proprietor ❑ I have Worker's Compensation Insurance Insurance Company Name: --(Qt"d Worker's Comp.Policy ('(i CC ,S00 SO( 8 fr J i)f,t WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares SO (SQ( 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: y A-". M..`a Lei 1 / IP-A-AS -Location of Facility f j I declare under penalties of perjury 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 denial or revocation of my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: Gy Owners Signature(or attachment) ,00/41k Date: / /c:1/117 Approved By: J Date: 1 `) R-II Building Official(or designee) EMAIL ADDRESS: Zoning District: Historical District: 01 Yes 7 No Flood Plain Zone: 1 Yes G No Water Resource Protection District: Within 100 ft.of Wetlands: 1 Yes _. No L Yes li No ONG_ 299 Main Street, West Yarmouth, MA 02673 508-775-6880 Fax: 508-775-6939 E-Mail: horansh@comcast.net September 11, 2019 To: Whom it May Concern, From: Shawn Horan Re: Foxwood II Condominiums Building P 248 Camp St, West Yarmouth Please note that L&M Home Improvement Inc has been retained to replace the siding located at Foxwood II Condos Building P. They are scheduled to start on Monday 9/16/19. Please call me if you have any questions. Sincerely yours, Shawn Horan Cape Realty Inc Property Manager SALES RENTALS REAL ESTATE MANGEMENT BUYER AGENCY www.caperealtycapecod.com The Commonwealth of Massachusetts _ l Department oflndustrialAccidents —:iel= a 1 Congress Street,Suite 100 __ 4_ Boston, MA 02114-2017 } �4� www mass.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): J1f1€ 4-YY3C-&,1IV..-.--(Address: 20 CLi.- („ 0 City/State/Zip: S-- Phone#: 01-3 7 f$92 Are you an employer?Check a appropriate box: Type of project(required): 1.E1 I am a employer with employees(full and/or part-time).* 7. ❑New construction I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 ❑ Building addition 4.0 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 11.0 Electrical repairs or additions proprietors with no employees. 12.Q Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.Q Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q 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 employee& Below is the policy and job site information. Insurance Company Name: A-cet-,, Policy#or Self-ins.Lic.#: C . 9C'3 S C 9S& A- Expiration Date: 641130 ( c'2-ô Job Site Address: ��( --COS--CO/4A c City/State/Zip: .. 444/1" 4-4/(1 Attach a copy of the workers' compensation policy declaration page(showing the policy number f1d 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 under the p 'ns and penalties of perjury that the information provided above is true and correct Signature: Date: ® 7- /G Phone#: 50a 3 its 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#: Commonwealth of Massachusetts �t �. Division of Professional Licensure Board of Building Regulations and Standards Constr tibti upp..rvisor CS-104107 ylcpires:08/25/2021 CARLOS H FtOUEIROA, t: 20 CAPTAIN NOYES SOUTH YARM9UTH 441.0664 U/bV1 Commissioner om,wCi?u,eci /- Office of Consu ��«elf ------ HOME IMP merAffairs&Business Regulation ROVEMENT CONTRACTOR TYPE:Corporation R 1 at n Ex it ion C&F REMODELING INC 01/07/2021 CARLOS H.FIGUEIROA 20 CAPTAIN NOYES RD. S.YARMOUTH,MA 02604 Undersecretary