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Home My WebLink AboutBLD-20-1391 S Office Use Only y:' .w D. Permit# x roallt ye o� y Amount ISO— ' ` NATTA n CSC 4' �' �ca?' 1\ Permit expires 180 days from ` 4''' I39/ _issue date EXPRESS BUILDING PERMIT APPLICATION _ .__ .__. _ _ _� ..__ __ TOWN OF YARMOUTH E ! <.. , E. 0 Yarmouth Building Department 1146 Route 28 4 SEE ] Ali i South Yarmouth, MA 02664 (508) 8-2231 Ext. 1261 , _ �.k ti j CONSTRUCTION ADDRESS: d5 /� , i.r ASSESSOR'S INFORMATION: ,�y� /Map: Parcel: 7 �i, �T OWNER: in C 4.1te�1 WMc�h-J 5?)FAO v l7Z/ NAME PRESENT ADDRESS TEL. # CONTRACTOR: Xsidential NAME MAILING ADDRESS TEL.# 0 Commercial //2(� Est.Cost of Construction$ Cea4 —p Home Improvement Contractor Lic.# 17 (Oc] / Construction Supervisor Lic.# (s /t / Wor.:1.a's Compensation Insurance: (check one) 1Ik I am the homeowner 0 I am the sole proprietor ❑ 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 7 Replacement windows:# ? Replacement doors: # Roofing: #of Squares ( )Remo e existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( Replacing like for like Pool fencing *The debris will be disposed of at: ��/M L Location of Facility I declare under penalties of perjury that the statements herein c ained 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 rosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: Owners Signature(or attachment) Date: ?c�//—/ 7 Approved By: Date: / — 1/ '9 Building 0 (o esignee) EMAIL DRESS: Zoning District: Historical District: 0 Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No . _ The Commonwealth of Massachusetts Department oflndustrialAccidents _Trim:_- 1 Congress Street, Suite 100 1�-s Boston, MA 02114-2017 M:. www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information / PIease Print Legibly Name (Business/Organization/Individual): �r�'``• 2e. Pi.,.4. 4/� Address: PO X /sr& City/State/Zip: 6 f/ /v/ ,'yid- 0.2 6 " Phone #: j d r 2 5'-7 .--/ Are you an employer?Check the appropriate box: Type of project(required): LEI I am a employer 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 rNSiy capacity. [No workers'comp.insurance required.] 8. ❑ Remodeling 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 mYP roPertY• 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. insunance.t 13.�►5 Roof repairs, 14.E • er :5 6.{:We are a corporation and its officers have exercised their right of exemption per MGL c. � 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. 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. 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 s -. ement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under tl pai;,• , ,penalties ofprjttiy that the information provided above is true and correct. Sian e•afar ' Date: 1 1/1/ Phone*: 5 Zip ?7 2/ 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#: Pixe Office of Consumer Affairs and Business Regulation One Ashburton Place - Suite 1301 Boston, Massachusetts 02108 Home Improvement Contractor Registration Type: Individual Registration: 151639 MICHAEL L PIMENTAL Expiration: 06/19/2020 P.O. BOX 1286 S.YARMOUTH,MA 02673 Update Address and Return Card. SCA 1 0 20M-05/17 riAP*Oil?711ontoeo d o/ 1�[JJJIiC�!(Je( 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 151639 06/19/2020 One Ashburton Place-Suit 1301 MICHAEL L PIMENTAL Boston,MA 0210 MICHAEL L.PIMENTAL 275 W.gST YARMOUTH RD Not valitro hout signature W.YARMOUTH,MA 02673 Undersecretary Details Page 1 of 1 Licensee Details Demographic Information Full Name: MICHAEL L PIMENTAL Owner Name: License Address Information City: South Yarmouth State: MA Zipcode: 02664 Country: United States License Information License No: CS-098881 License Type: Construction Supervisor Profession: Building Licenses Date of Last Renewal: 11/20/2017 Issue Date: 11/9/2011 Expiration Date: 11/9/2019 License Status: Active Today's Date: 9/11/2019 Secondary License Type: Doing Business As: Status Change Reason: License Renewal Prerequisite Information No Prerequisite Information No Available Documents https://madpl.mylicense.com/Verification/Details.aspx?result=76b34f87-cd97-43bd-a9ad-f... 9/11/2019 %.%, lam' ii<KA:eivED! ' 41.• TOWN OF YARMOUTH ALE. 21 2U S 1146 ROUTE 28, SOUTH YARMOUTH, MA 02664-4451 Telephone(508)398-2231 Ext. 1292—Fax(508)398-0836 YAklviOUTH RE IN NG'S HIGHWAY HISTORIC DISTRICT COMIIf1T-E S HIGHWAY SEP 1 1 2019 APPLICATION FOR TOWN CLERK CERTIFICATE OF APPROPRIATENESS ]�1R A WAila -Firtici4 br issuance of a Certificate of Appropriateness under Section 6 of Chapter 470, Acts of 1973 as amended,for proposed work as described below&on plans,drawings, photographs, &other supplemental info accompanying this application. PLEASE SUBMIT 4 copies OF SPEC SHEET(S), ELEVATIONS, PHOTOS, &SUPPLEMENTAL INFORMATION. Check All Categories That Apply: Indicate type of Building: Commercial Residential 1) Exterior Building Construction: New Building Addition Alterations Reroof Garage Shed _Solar Panels Other: 2) Exterior Painting: Siding Shutters Doors _Trim Other: Q�1rAle- OLOr cco`' I 3) Signs/Billboards: New Sign Change to Existing Sign 4) Miscellaneous Structures: Fence Wall Flagpole Pool Other: Please type or print legibly: (� A Address of proposed work: 1 1 JY of tvk no- Map/Lot# IS) 52 Owner(s): MI CiLae I ?I me N Phone#: 501 aP10 c "c) 1 All applications must be submitted�ed by owner or accompanied by letter from owner approving submittal of application. Mailing address: PO (QX ).914 (0 6,1 A-w oo...Pk G Year built: I I 0 Email: ic t1 tic kL o-e-A 0 e & , co(v1 Preferred notification method: Phone ✓ Email Agent/contractor. 6aWIe_ Phone#: Mailing Address: Email: Preferred notification method: Phone Email Description of Proposed Work: Ch��5 �►�►ri -o,�. -o4 kotis, I-0 LA) C€'7 4-rr e ce 9 Li to�r>,s remo one c'# door add 51`ylty Li- Oil Ys< fY1 a� ,i1ec)(- r kcz GtectL-inci an %XLS Signed(Owner or agent): 4 Date: a> fC > Owner/contractor/agent is aware that a permit is required from the Building Department.(Check other departments,also.) > If application is approved,approval is subject to a 10-day appeal period required by the Act. > This certificate is good for one year from approval date or upon date of expiration of Building Permit,whichever date shall be later. > All new construction will be subject to inspection by OKH.OKH-approved plans MUST be available on-site for framing&final inspections. For Committee use only: Approved V Approved wit . odifications Denied Rcvd Date: gla t) !q Reason for Denial: Amount 1I tj - Cas i /n'�IG 1 _ Signed: / ✓ { Rcvd by: � 45 Days: /D' 2-- Q/ 7 Date Signed: T (4 i -°f 1 -_ I / 1 APPLICATION#: ! 9 ® A073