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Home My WebLink AboutBld-20-003029 O ,�,aRAy Office Use Only 01..).-1) s,t; L O O - i € /H Amount F MAT.- 1 S ,, ♦.�,�,„1.,. ,. Permit expires 180 days from issue date EXPRESS BUILDING PERMIT APPLICATION- Ni E TOWN OF YARMOUTH -- Yarmouth Building Department 4 1146 Route 28 1 f South Yarmouth, MA 02664 i ;i D ,. F A K .. .i E N T (508) 398-2231 Ext. 1261 "` CONSTRUCTION ADDRESS: I 1 5- f=VE 1V '17R' V rV W . Y ii/M 0 UTH1 /14 ASSESSOR'S INFORMATION: Map: G 1 Parcel: 6 2.-- ZA' 4t4 f-/ It, ttt,4 jA,r OWNER: Ric AR I) ,1,L-1D4/ i .7 Ste-ud-it A/„i,8- l• ti/rn#uTK/.1,'# 42 6 7? NAME / PRESENT ADDRESS TEL. # CONTRACTOR: G4/Zy 0(//1Arion ( Pi ?i. i cw c 2'0iii die u .iti&N1 14,9r ASP da/n x/, NAME MAILING ADDRESS TEL.# e 04.//f, H4 e ZA re 1-6 v,i c5. Residential ❑Commercial Est.Cost of Construction$ Home Improvement Contractor Lic.# l°o 7.1° Construction Supervisor Lic.# 65 0 1 Y4 Vj Workman's Compensation Insurance: (check one) V f I am the homeowner�j -`I am the sole proprietor -II have Worker's Compensation Insurance Insurance Company Name: '7 li O(14 izG ZNi. 474 NY Worker's Comp.Policy#_ w G g a I / 2 ]-2-- WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove I c a Siding: #of Squares Replacement windows:# Replacement doors: # Q a 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:70 CO A-) t)Y y4 nme i/T a L 4/VA I Location of Facility 1 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 atio f my license and for prosecution under M.G.L.Ch.268,Section I. Applicant's Signature: Date: I r l 2.Z //S Owners Signature(or attachment) `f 6E A 17-4 d Date: Approved By: , , Date: V -1.c'' I Building Official(or designee) EMAIL ADDRESS: Zoning Di tct: Historical District: Yes No Flood Plain Zone: Yes No Water Resource Protecti District: Within 100 ft.of Wetlands: - Yes o Yes No The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street • =`' Boston,MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): CAPIZZI HOME IMPROVEMENT INC Address: 1645 NEWTOWN ROAD City/State/Zip: COTUIT MA 02635 Phone#: 508-428-9518 Are you an employer?Check the appropriate box: Type of project(required): 1. ✓ I am a employer with 40+ 4. I am a general contractor and I 6. New construction employees(full and/or part-time).* have hired the sub-contractors 2. I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling ship and have no employees �ese sub -contractors have 8. Demolition workingfor me in anycapacity. employees and have workers' p �' 9. Building addition [No workers' comp.insurance comp.insurance.: 10. Electrical repairs or additions required.] 5. We are a corporation and its eP 3. I am a homeowner doing all work officers have exercised their 11. Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12. Roof repairs insurance required.]t c. 152, §1(4),and we have noV 4 employees. [No workers' 13. Other 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: AMGUARD INSURANCE COMPANY Policy#or Self-ins. Lic.#:R2WC9211272 Expiration Date: 12/25/2019 Job Site Address: 1 7 5+-e k 3)IZ4 v4 City/State/Zip: W ' 1 j 4/Z'`f b vTH Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify u er th • and penalties of petjury that the information provided above is true and correct Si ature: Date: 'I / 3 / ,c Phone#: 50 8-0269 Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Commonwealth of • Division of Professional Board of Building Regulation _ Construt5114 101 .mot fF. CS-074640 ,1 • te$ • GARY GUSTAFSON a SHORT WAY SANDWICH MA 42663 Commissioner C HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Supplement Card before the expiration date. If found return to: Basidcallas Essinikia Office of Consumer Affairs and Business Regulation 100740 06/22/2020 Ons Ashburton Place-Su 1301 CAPIZZI HOME IMPROVEMENT,INC. Boston,MA 02108 • GARY GUSTAFSON ` �--- 1645 NEWTON RD. COTUIT,MA 02635 valid without signature Page 6 of 6 Capizzi Home Improvement Inc. Specifications and Estimates STATE OF MASSACHUSETTS LETTER OF AUTHORIZATION TO APPLY FOR A BUILDING PERMIT WE,RICHARD AND BARBARA MILTON, OWN THE PROPERTY LOCATED AT 17 STEVEN DRIVE IN WEST YARMOUTH, MASSACHUSETTS. I HAVE AUTHORIZED CAPIZZI HOME IMPROVEMENT TO ACT AS MY AGENT TO APPLY FOR A BUILDING PERMIT IN ACCORDANCE WITH 780 CMR, THE MASSACHUSETTS STATE BUILDING CODE. l I GIVE MY PERMISSION TO C�/�b/�zj /.'� ny - ._2.17 !^2,1/ ,cic i LESSEE TO APPLY FOR A BUILDING PERMIT IN ACCORDANCE WITH 780 CMR, THE MASSACHUSETTS STATE BUILDING CODE. SIGNATURE OF OWNER: 71tet'✓ OWNER'S ADDRESS: 17 STEVEN DRIVE, WEST YARMOUTH MA 02673 OWNER'S TELEPHONE: 508-694-7311 LESSEE'S SIGNATURE: LESSEE'S ADDRESS: LESSEE'S TELEPHONE: APLLICANT'S SIGNATURE: APPLICANT'S ADDRESS: 1645 Newtown Rd., Cotuit, MA 02635 APPLICANT'S TELEPHONE: 508-428-9518 RESPONSIBLE OFFICER: RESPONSIBLE OFFICER ADDRESS: RESPONSIBLE OFFICER TELEPHONE: