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HomeMy WebLinkAboutBld-20-001510 • Office Use Only .. O�.yli Permit# O 4 47 H Amount t / ) c� 't --I„ •4'. Permit expires 180 days from _20 S t c� B r issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH REF 17 20i9 Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: �J5, Ce4p4)-(`,..J I)C) Y1E . li2_ ) • D. ,/(YV'''''caz-e--e-* ASSESSOR'S INFORMATION: Map: Parcel: �9 OWNER: /1 4"1,cep-, ,�� S3 . c/it','- ,0G v' SW , 3‘0/f t i- NAME PRESENT SS TEL. # CONTRACTOR: aa`,, �,.'„-!.L l� uJ i �Gl,/G✓ k2 508 a3 2�'sg. _ N MAILING AD SS ( TEL.# '4.-8-Residential ❑Commercial Est.Cost of Construction$ 3.(00- oc Home Improvement Contractor Lic.# fJ 3 7 q Construction Supervisor Lic.# l 0 // /0 '-- Workman's Compensation Insurance: (check one) ❑ I am the homeownerI am the sole proprietor ❑ I have Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy# '(l C-C-JCO. 50(958 T' 94- 1.„c0 WORK TO BE PERFORMED SD Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares IC C) 9) 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 dr)j -r Location of Facility I declare under penalties of perjury that the state is 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 , e and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: /211 Date: d ?%�'/ Owners Signature(or attachment) '( _ Date: G Approved By: t 4 `�.. Date: r( ,/ ) -)J Building Official ••—.. -e) EMAIL ADDRESS: Zoning District: Hi orical District: 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes ❑ No The Commonwealth of Massachusetts I _,,4 I. IDepartment of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 '.1M f..,''''� _ www.mass.gov/dia \Y orkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organizati n/Individual): € �� ,64/Y7 Address: Ze/ 49-t ("-- ifs p _o S City/State/Zip: S . i_,,�J/t Phone #: 5 Oig Y3 195 -& Are you an employer?Check the apropriate box: Type of project(required): 1.0 I am a employer with employees(full and/or part-time).* 7. E New construction 04E-I am a sole proprietor or partnership and have no employees working for me in 8. E Remodeling any capacity. [No workers'comp.insurance required.] 9. ❑ Demolition 3.E I am a homeowner doing all work myself. [No workers'comp.insurance required.]t 10 E Building addition 4.E 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.E Electrical repairs or additions proprietors with no employees. 12.E Plumbing repairs or additions 5.E I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.E 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.E 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. 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.#: G_C Q ` Expiration C )Ze/C/ �C, s G �J�-�'► ��9 Expiration Date: ,� / Job Site Address: S 5 Cr (.,-- ve-- S. City/State/Zip: 5'/14Attach a copy of the workers' compensation policydeclaration age the olic numbex expiration date). page(showing policy P ) 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 u der *.e pains and penalties of perjury that the information provided above is true nd correct. Signature: �� ��� Date: illCPr/' /7 Phone#: $ Ye 3 7 9" ,..5 92 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#: tvriirztnttw¢tft �iClJiQCt�effJ Office of Consumer Affairs J3<Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Corporation Registration Expiration 153792 ; ; 01/07/2021 C&F REMODELING INC CARLOS H.FIGUEIROA 20 CAPTAIN NOYES RD. tJl S.YARMOUTH,MA 02604 Undersecreta Commonwealth of Massachusetts ? t Division of Professional Licensure Board of Building Regulations and Standards Constrl�ct-On1Sdpervisor CS-104107 }. �ires: 08/25/2019 CARLOS H FIGUEIROA# -' 20 CAPTAIN NOYES SOUTH YARMOGI.TH M £12164. ,y Commissioner V4 corn:'re.f__titn•Cet3i: .aiF r.i't_€a Ltd -c 4zC1-ar J _'c:_ _,_ - Search... letails X The Official Wetrsrfe of the Executive Office of EOHED arid Diesion of Professional Licensure air Public Safetyt411 6a rtas=cos K� �,;e �r�iz e��,e_ 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 Change Reason: License Renewal Prerequisite Information No Prerequisite Information No Available Documents Close Window I ©2011 Commonwealth of Massachusetts Site Policies I Contact Us Intern t c; 0j