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Home My WebLink AboutBld-20-001290 •: Use Only } oir • try G i w 0 '�x+!'1. . .H Amount 4 =.r_ .IArri.cn cad ' S '""'T`° cam Permit expires 180 days from issue date EXPRESS BUILDING PERMIT APPLIC F ` TOWN OF YARMOUTH i (', 1' ,ji ti. Yarmouth Building Department � ��1-1- �� , 1146 Route 28 B; f South Yarmouth, MA 02664 `,Y_____ = " -` Q (508) 398-2231 Ext. 1261 �CONSTRUCTION ADDRESS: /OYq 't 2v ap it LADY a P Sot *IvY GN$L ASSESSOR'S INFORMATION: Map: Parcel: OWNER: 4T MIS X Arrant.' G4 ftcnoF FA It An A. 5 f ¢ ►Sr co•YAtrogto 6iS • 27g. 2148 NAME PRESENT ADDRESS TEL. #p CONTRACTOR: {A'L 6guP, /NG (4 ,IoMAitiq Mis145Airl.Q MA 5O • ?S'S • it&5% NAME MAILING ADDRESS TEL.# ❑Residential ` Commercial Est.Cost of Construction$ 2 6 Home Improvement Contractor Lic.# 1%7 10 3 Construction Supervisor Lic.# C S-Q S 7 2.2.2 Workman's Compensation Insurance: (check one) ❑ I am the homeowner 0 I am the sole proprietor CO. I have Worker's Compensation Insurance Insurance Company Name: Nor 4.Fl dd / t v(4 it CO Worker's Comp.Policy# 69502.031P61251117 WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares 37 ( N Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: SEA) 4 RoC Silo s *A Location of Facility I declare under penalties of rj ',g,t 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 deni re Tr.tion.f, y license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: ./ Date: !p I I. I ' 2 0) 1q Owners Signature(or attachment)�� Iii j (11.4.>A , /ct--._.----- Date: iv /q, 22-ct Ck _C\_)j Approved By: ✓' 1., Date: Building Official(or designee) EMAIL ADDRESS: 74/4 h 2.4 1 r.,.,..,, C i w1 s;i , cc.; j Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: 0 Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes ❑ No '''� The Commonwealth of Massachusetts .y _+=, L Department of Industrial Accidents w _F s 1 Congress Street, Suite 100 _ T_ ' Boston, MA 02114-2017 M�, .•"' www.mass.gov/dia Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): P41 Awi4 &1210, INC . Address: " Z' 41/ Mp i;) S f City/State/Zip: 144a„41414 , libt, DW1S Phone #: 50S ' if S ' t L CS Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.0 I 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 mYP roPrh'•e 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. 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: 1d 4[�T pt. 2$ - 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 verifica• I do hereby feta t1 e pains and penalties of perjury that the information provided abo e is tr e and correct. Signature: Date: ` 7 ZIP' Phone*: 50,' if t' Lt4C6 • 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#: t -- i A 1 , A a ►. ,_ PLANNING . DESIGN . CONSTRUCTION 625 NORTH MAIN STREET MANSFIELD, MA 02048 September 9,2019 To: Yarmouth Building Department From: Thomas Palanza, PALANZAGROUP, INC. RE: 1044 Rte.28 Our Lady of the Highway To whom it may concern: I,the undersigned, Edward Sousa,hereby acknowledge that I will be the onsite construction supervisor(CSL 087222)for Palanza Group, Inc. (General Contractor)for the above-captioned project. e04,frPLA-- c Edward Sousa Date ra4"4 Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Constar lt'upervisor tS-0i7222 :;,` Ejr Tres 110712019 ammo F Itil!1f FALL RIVER Cet, ner ( pry�flRlBffilt? //// /J• .. Office of Consumer Affairs&Business Regulation• HOME IMPROVEMENT CONTRACTOR 1 TYPE:Individual Registration Expiration 187463 04/12/2019 EDWARD F.SOUSA D/B/A C&E CONTRACTORS EDWARD F.SOUSA 87 HYACINTH ST FALL RIVER,MA 02720 Undersecretary