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Home My WebLink AboutBld-20-000377 ,Y - Office Use Only �!� y O . :„` Amount *4?""1"::' (C6' Permit expires 180 days from E issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 (508) 398-2231. Ext. 1261 CONSTRUCTION ADDRESS: /9 (/J f,/) L,S AFL' ASSESSOR'S INFORMATION: � Map: 7a7 Parcel: f OWNER: Q ?br-t w' nS ( -1 `'o l u rAllt ti AVM' /M:1-0-01\ N PRESENT ADDRESS TEL. # CONTRACTOR:at(C110C., 1 671 Z r- /av �A-/J ?c O Z�7 7 O NAME MAILING ADDRESS TEL. 120-2-3 f-'100 0 Residential 0 Commercial Est.Cost of Construction$ Jai 9Z 5 Home Improvement Contractor Lic.# /698 313 Construction Supervisor Lic.# IDl/55 Workman's Compensation Insurance: (check one) 0 I am the homeowner CRC I am the sole proprietor LI 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 Replacement windows:# 3 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: c.[i/K S -O C 'r 5 ( / N/�' Location of Facility 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 o ' y lice id for p ecution under M.G.L.Ch.268,Section 1. Applicant's Si!, „ : Date: ?/' r /T q Owners Si' 'attire(or attic eat) Date: 1 Approved By: Date: �']" 21' /S Building Official esi EMAIL ADDRESS: Zoning District: Historical District: 0 Yes Li No Flood Plain Zone: Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: D Yes ❑ No 1 Yes 0 No The Commonwealth of Massachusetts 1� Department of Industrial strial Accidents 1 Congress Street,Suite 100 Slit;1= Boston, MA.02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Aoolicant Information Please Print Legibly Name (Business/Organization/Individual): etfrl �t2,p Address: 02— Ws-ty ?4-t„) City/State/Zip: M4-- o z-1r D Phone#: "1 ex) Are you an employer?Check the appropriate box: Type of project(required): 1.Q I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.01 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 doingall work t 9. ❑Demolition ❑ myself[No workers'comp.insurance required.] 4.❑I am a homeowner and will be hiring contractors to conduct all work on my p t�ru tY. I will 10 El 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 13.Q Roof repairs These sub-contractors have employees and have workers'comp.insurance.: 6./0 We are a corporation and its officers have exercised their right of exemption per MGL c. I4 -Other (rV/�c�w �e{� 6.✓f 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 tContractors 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 under the p ' and pen ' of perjury that the information provided above is true and correct Signature: Date: ? /9 Phone#: 7Zo- z,3(_ 70Cc) 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): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: March 31, 2019 410 _.,r►"'- Proposal #19001902 Building Dreams, Inc. 692 Walnut Plain Rd Rochester, MA 02770 720-231-7000 Mike@buildingdreamsinc.org Proposal FOR 19 Columbus Ave 19 Columbus Ave West Yarmouth West Yarmouth, MA Window replacement Permits Trash removal Install new 5'0 by 4'1"Anderson picture window with new exterior trim $1,180.35 Exterior flashing to be replaced as needed Interior trim to be removed and replaced with original material Install two new 2'3"x 4'1"Anderson double hung window with new exterior trim $1,685.42 Exterior flashing to be replaced as needed Interior trim to be removed and replaced with original material Replace three interior sills at picture windows $510.00 All exterior trim replaced to be Azek Upgrade to ipact resistant glass would add$230.00 per window Interior painting of window trim additional$50.00 per window Replace boarding below three picture windows(painting not included) $550.00 Total $3,925.77 Proposal is valid for 30 days. 1/2 due upon acceptance. / _ THANK YOU! fry 1 / Commonwealth of Massachusetts %� 6v9r/1T,W«<er7 / r Jga�42c/sve1G� ;1� Division of Professional Licensure Office of Consumer Affairs&Business Regulation Board of Building Regulations and Standards �� i HOME IMPROVEMENT CONTRACTOR ConstrdfCtl�tt �ilpervisor TYPE:Individual • /t Registration Expiration - CS-101155 �ires: 08/27/2020 68313 02/19/2021 '° MICHAEL WILLIAMS MICHAEL A WILLIAM, 692 WALNUT PAIN R =: MICHAEL WILLIAMS C — —' ROCHESTER MAI 027/0- .,1`\ 692 WALNUT PLAIN RD �� v ��1��i tl ROCHESTER,MA 02770 Undersecretary4.,E', Commissioner Ch