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Home My WebLink AboutBld-20-000045 .61,�, Office Use Only . Permit# . C 50_, O 't� .3. Amount ��MA . * . c07. Permit expires 180 days from issue date ::�►:, BLb -,I-,-"LIS EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH la L 2019 Yarmouth Building Department 1146 Route 28 CV--* 5a3 South Yarmouth, MA 02664 K (c)n(jes (508) 3398-2231 Ext. 1261 CONSTRUCTION ARESS: ( V I L na� �� \/ck cm(JA \ mcl ASSESSOR'S INFORA:ATION: Map: Parcel: OWNER: 177 A rC-i,9 v /�r�<I/'✓c1 fI C. L.- ,20 ("hi ie S-S)t}/„.„/ r . y. P 5 J .,d,2 I - 26-o NAME PRESENT ADDRESS TEL. # CONTRACTORj\\v(i ec,0\ ' 5 d} MF-)- fi,e I� ,{11YI GCV , l 53 (43«e tccc& Ok ) ' - 90cic- Li 6q(t�(c NAMELING ADDRESS TEL.# COResidential 0 Commercial Est.Cost of Construction$ 35 00, C Home Improvement Cantractor Lic.# k e j Construction Supervisor Lic.# , — l bt. 1 s, 1 Workman's Compensation Insurance: (check one) :1 I am the h.:•neowner ::: I am the sole proprietor E 'I have Worker's Compensation Insurance Insurance Company Nan:,c 1C- C C1�J Q, (2 j Worker's Comp.Policy# MU(2) 0I 1 H kJ 13 ±-i 9 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) Insulation NV d Kings I.li hwa /Historic Dist. t�g g y ( eplacing like for like i2 Pool fencing *The debris will be disposed of at: (6 ex (_,R l g,(�d j y;.►.2., .,,, t (,n TA I t i C-r _,,(e 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 of icense and for prosecution under M.G.L.Ch.268,Section 1. tt l Applicant's Signature:�� Date: 3 U 1 \1 Owners Signature(or attachment) )2 i_z-L. ., �� . Date: 6/30 /f Approved By: - Date: — k — I S Building Official(or designee) EMAIL ADDRESS: Zoning District: Historical District: r Yes No Flood Plain Zone: Yes C No Water Resource Protection District: Within 100 ft.of Wetlands: .7 Yes :_ No Yes _.I No The Commonwealth of Massachusetts Department of Industrial Accidents w 'ee%�ls 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/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):M6 A,VIA.C., I c'( c II2A`(l (j Address: 53 l*.,9% nnd\ Dr J City/State/Zip: ya(,md,,' (1----" Mc\ 0,av15 Phone#: OS -31 `-( -qq CD(0 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 2.Q I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.0 I am a homeowner doing all work myself. [No workers'comp.insurance required.]t 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. 12.0 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.t 14.ElOther V-40,0,C 6. We are a corporation and its officers have exercised their right of exemption per MGL c. � L.)-; 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. 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: �CL y , (' S Policy#or Self-ins.Lic.#: 1 PIUC. \'-1N\3--q-`61 Expiration Date: 02 I CS /3 D Job Site Address: QD WC1 V SS( 0 \ C)C- City/State/Zip: Va(rn i,7Crt mU OR(o7_5 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 pains and penalties of perjury that the information provided above ' true a/id correct. Signature: �� _ Date: (.P /30/I ' J Phone#: 5 CD c� - _I -qC (aQ 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 Massachusetts Division of Professional Licensure Beard of Building Regulations and Standards Construction Supervisor CS-102185 Expires: 1212612020 KARL T SPAIN 46 MAIN STREET - 4- SANDWICH MA 02563 Commissioner e ►wealdi sibliossaammelk OIUoe of Consumer Affairs&Heeinss Be ehrio n HOME IMPROVEMBIT CONTRACTOR Registration valid for individual use only TYPE:dear bstorelbeaspbstIondote. If found return to: CAlikiliN6 Olen of Consumer Maim mid Buskins Regulation • -1 -'- 0202l2 20 One Ashburton Pace-suits 1301 KART.SPMN = Boston,MA D/B/A KT.SPAiN__ - • _ = v KARLSPAW 2-CCQ.p� 46 MAW ST. SANDWICH,MA 02563. Ee3 • ^ VBRd NOTICE NOTICE TO —_ -�►� TO EMPLOYEES = — �� EMPLOYEES 1,4 = Sv e The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 1 Congress Street, Suite 100, Boston,Massachusetts 02114 — 2017 617-727-4900 — http://www.state.ma.us/dia As required by Massachusetts General Law,Chapter 152,Sections 21,22&30,this will give you notice that I(we) have provided for payment to our injured employees under the above mentioned chapter by insuring with: THE TRAVELERS INSURANCE COMPANIES NAME OF INSURANCE COMPANY P.O. BOX 1450 MIDDLEBORO. MA 02344-1450 ADDRESS OF INSURANCE COMPANY (7PJUB-0114N13-4-19) 02-08-19 TO 02-08-20 POLICY NUMBER EFTECTIVE DATES BRYDEN & SULLIVAN INS PO BOX 1497 += SOUTH DENNIS MA 02660 NAME OF INSURANCE AGENT ADDRESS PHONE# op M.B. HOME IMPROVEMENTS, INC. 53 CONGRESSIONAL DR o� YARMOUTHPORT MA 02675 EMPLOYER ADDRESS • EMPLOYER'S WORKERS COMPENSATION OFFICER(IF ANY) DATE pmme MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the services provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably •M connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS .1 sae W2OPIG15 TO BE POSTED BY EMPLOYER Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type Corporation 80881 M.B.HOME IMPROVEMENT,INC. Registration: 1/2212021 53 CONGRESSIONAL DR Expiration: 01J22/ YARMOUTHPORT,MA 02675 Update Address and Return Card. SCA 1 15 20M-0511177 • 17 /; , Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE.Corporation before the expiration date. If found return to: Rtaislnitien Office of Consumer Affairs and Business Regulation t8088 01/22/2021 1000 Washington Street-Suite 710 M.B.HOME IMPRO JEMtritt 41G. Boston,MA 02118 MICHAEL BERNSTEIN C �-- - !_ 53 CONGRESSIONAL DR YARMOUTHPORT,MA 02675 Not valid without signature Undersecretary chat". ; ._.-c'e ssillaxALDri IIIIi : _ n ►e tt n m ._6-_ rid. T--1p rc erne hLcd_Q34 . __ 3u _Conk()_ . _pCi 1 1_ = -- --