Bld-20-001370 F; Office Use Only a
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O'.4• '•` r Permit# �r
7,y y' Amount u
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-_ ;;--=••.. iI issue date
EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH i
Yarmouth Building Department S�� 1 l ��
1146 Route 28 ? `
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS: fil 17F�- COO ei S cs `^'-`5)1
ASSESSOR'S INFORMATION:
_ , Map: c� rib-Al Parcel: �I N
(XOWNER: 4 nti d f7',nt f / < ENT ADDRESS Dry S5. /_ .�6f -3/ y"/ '/7
\ /c k Q, ,n C��
CONTRACTOR: 42 ChCce.7 ?AlieN'°�'1 &X /2 S %C#7 f 2O-' '72/
NAME MAILING ADDRESS TEL.#
JP
residential ❑Commercial Est.Cost of Construction$ c 000
Home Improvement Contractor Lic.# 6/09 Construction Supervisor Lic.# 09,,p O 7
Workman's Compensation Insurance,; check one)
0 I am the homeowner I am the sole proprietor 0 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: # Replacement doors: #
Roofing: #of Squares /2-- ( )Remove existing*(max.2 layers) Insulation
Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing
*The debris will be disposed of at: � 1. ;
h<1
Location of Facility
I declare under penalties of perjury that the stateme• e :�. ained ar- . - .i d 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 m ce•.:- an, E .rosecution under M.G. . . 68,Section 1.
Applicant's Signature: Date: _//
ners Signature(or attachment) ! / :8—, ih / ,"/ Date: /!��,-'
Xpproved By: ..G i Date:
Building Official(or designee) EMAIL ADDRESS:
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
-A 1 Congress Street, Suite 100
_ �- Boston, MA 02114-2017
1'.,,;�5.•`'4 _ www.mass.g
jjov/dia
orkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information / Please Print Legibly
A�Name (Business/Organization/Individual): .C /J_ /�Ee4 Y '/
Address: ?d gOX /2
City/State/Zip: 5/C1' 'I O7o6% Phone #: SZ1? 2.F-0 9-7_2-/
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
10
am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling
capacity.[No workers'comp.insurance required.]
3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
9. ❑ Demolition
10 ❑ Building addition
4.❑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 11.0 Electrical repairs or additions
proprietors with no employees.
12.0 Plumbing repairs or additions
5.11 I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13Roof repairs
These sub-contractors have employees and have workers'comp.insurance.: ****"'�
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c.
14.El 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: 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 states - t may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify under the '• ns d pe allies of perjury that the information provided above is true and correct.
Signature: 4111, Date: / J//---/
Phone#: ff 28z) 9
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#:
CIS aid
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�
r� G ix /
�e t[onmontoea�(Ao/ 77(wreArtje/%i
Office of Consumer Affairs&Business Regulation 9
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 j i
MICHAEL L.PIMENTAL lLCGQ
275UV ST YARMOUTH RD Not valia'wi hout signature
W.YA.MOUTH,MA 02673 Undersecretary
..� --
Details Page 1 of 1
Licensee Details
Demographic Information
'Full Name: MICHAEL L PIMENTAL
caner 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
hops://madpl.mylicense.com/Verification/Details.aspx?result=76b34f87-cd97-43bd-a9ad-f... 9/11/2019