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Home My WebLink AboutBld-20-001371 :A Office Use Only Y v • t -� 4.• �T----. Et Permit# Ou mil .�H Amount / . O a :` MATT ,, CS "" _�, Permit expires 180 days from kLb-zo-13 ( .issue date , EXPRESS BUILDING PERMIT APPLICATION .— __- TOWN OF YARMOUTH Fr. E C, ' ' t , � ),. Yarmouth Building Department 1146Route28 E 2Cif� South Yarmouth, MA 02664 :, (508) 398-2231 Ext. 1261 ic-_, CONSTRUCTION ADDRESS: 93 2 RT C A A RI-tot)7►-(Fort--4 ASSESSOR'S INFORMATION: Map:. I Parcel: OWNER: 2�'1-1 O R/4 0/0 CONTRACTOR:NAME )me PRESENT ADDRESS 7 /z4 $ TEL. #Ac4c. NAME MAILING ADDRESS TEL.# ❑Residential SCommercial Est.Cost of Construction$ /5e Home Improvement Contractor Lic.# /. ,/ ‘3 5' Construction Supervisor Lic.# 69 7237/ Workman's Compensation Insuranc check one) ❑ I am the homeowner I am the sole proprietor ❑ 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 ( )Remove existing* (max.2 layers)VIVO. Old Kings Highway/Historic Dist. (./)Replacing like for like Pool fencing *The debris will be disposed of at: Nitta"S TL3 2 A! Le,CA'1 I oik-) Location of Facility I declare under penalties of perjury that ments herein contained are true and correct to the t of my knowledge and belief. I understand that any false answer(s) will be just cause for denial or rev on of in3i,lic se. •,.rosecution under M.G.L h.Am 9 ? C� / Applicant's Signature: Date: - - i Owners Signature(or attachment) 11171e, Date: Approved By: Date: Building Official(or designee) EMAIL ADDRESS: Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes ❑ No 0 Yes 0 No The Commonwealth of Massachusetts f •_ , —_ Department of Industrial Accidents 1 Congress Street, Suite 100 OR= Boston, MA 02114-2017 ` www.mass.go v/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): //�2G, e L / Loy. -' Address: fed SOX /.Z-Fjo City/State/Zip: 5,/#1 '7 /114 024451 Phone #: f 2,6 97?/ 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 2K am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling ny capacity.[No workers'comp.insurance required.] 3. I am a homeowner doing all work myself. 9. ❑ Demolition ❑ y [No workers'comp. insurance required.] 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.❑ 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.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.t /�f 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other GJ/f'1GY'OwS 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 statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under t a es of perjury that the information provided above is true and correct. Signature: Date: 97/19 c� Phone#: sorzrb / i21 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#: Details Page 1 of 1 Licensee Details Demographic Information Full Name: MICHAEL L PIMENTAL Owner 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 https://madpl.mylicense.comNerification/Details.aspx?result=76b34f87-cd97-43 bd-a9ad-f.. 9/11/2019 2� (67 �� 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 d,, 20M-05/17��c A on,monwea/I�e/n/(l7JJaeA(uJffti Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Individual before the expiration date. If found return to: Reaistration Expiration Office of Consumer Affairs and Business Regulation 151639 06/19/2020 One Ashburton Place-Suit 1301 MICHAEL L PIMENTAL Boston,MA 0210/7/ MICHAEL L.PIMENTAL ,Q G `1�275W,EST YARMOUTH RD Not vali�'wi hout signature W.YARMOUTH,MA 02673 Undersecretary