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Home My WebLink AboutBld-20-002651 -.. .Y`9R Office Use Only 01''-, . .I' O Permit# OG. '1'1' ..21.1 ?Amount S L MATTA M CSCJ� �``"'°.u.. c 'Permit expires 180 days from 'issue date EXPRESS BUILDING PERMIT APPLICATIO N E , V '. TOWN OF YARMOUTH Yarmouth Building Department 5 _ J". ")f O 1146 Route 28 South Yarmouth, MA 02664 �' 1 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 6'g 7j/ 2 £/- W . Y,9csio u-/ 4 ASSESSOR'S INFORMATION: Map: Parcel: OWNER: / 74-7,- fl C pal 'c -e--.S"¢J dI NAiVIE PRESENT ADDRESS TEL. # CONTRACTOR: p1f C�1 Y R 4 LQ V 1 cI 2-3 0 NAME MAILING ADDRESS TEL.# QResidential 0 Commercial Est. Cost of Construction$ Home Improvement Contractor Lic.# 1 2 ! VTZ,o Construction Supervisor Lic. i�l30 s� Workman's Compensation Insurance: (check one) j 0 I am the homeowner 0 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 Lj' ( emove existin (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: At12--P"-ert.C.-‘74ADain? Location of Facility I declare under penalties of perjury that th- ,:tem- 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 revocatio o y,'ense and for prosecut'.n under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: ( 66 L. /25 Owners Signatur or attachme 30 Date: Approved By: Date: r/ /7 Building Official es' ee)�f EMAIL AD S: Zoning District: Historical District: 0 Yes ❑ No Flood Plain Zone: ❑ Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: Yes 0 No 0 Yes _ No The Commonwealth of Massachusetts _ 1 Department of Industrial Accidents v"e 1 Congress Street, Suite 100 =d �= Boston, MA 02114-2017 www.mass.go v/dia \Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): -i,9 .Y/'� %il�f�r�t/i Address: City/State/Zip: C S NVS. Phone #: , P o 220 / ` • Are you an employer?Check the appropriate box: Type of project(required): I. am a employer with p oyees(full and/or part-time).* 7. ❑New construction 2.0 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.❑I am a homeowner doing all work myself. [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 6.❑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.1 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑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 i urance for my employees. Below is the policy and job site information. Insurance Company Name: _ l�t'✓� `1 I Policy#or Self-ins. Lic. #: tat"S -0/9 xpiration Date: �� // C Job Site Address: CP7-0-P4 n.70--0( City/State/Zip: (Art Put.-® 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 and the pains enalties of perjury that the information provided above is true and correct. Signature: Date: IC 2A Phone#: ' "' Q —/ 4i 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#: rrEstimate /11r:1111111111r;\ BEL ISLANDS mate# Home Improvement 9/3n019 1066 Bel Islands Home Improvement 204 Cinderella Terrace Name tAckiress Marstons Mills, Ma,02648 Mary ary McPherson 68 Taft road, Belislandsroofingandsiding.com West Yarmouth,Ma 508-280-1794 508-364-6909 Terms Project pton t ,ty Rate Total POSSIBLE EXTRA: Any rotted plywood,trim boards,lead flashing or other carpentry needing replacement will be done and charged for as an extra at rate of$60.00 per hour,plus 15%mark up materials Bel ISlands Home Improvement Guarantees the labor for Lifetime of roof and against Blow-offs for 15 Years. Bel Islands Home Improvement:Carries Worksman's Compensation and Public Liability Insurance on the above work, certificate available upon request permit 250.00 250.00 dumpster 550.00 550.00 `iY , .' ( > a Ael, `U /7/W/9 Total $9,550.00 Page 2 nJ,4e n»Imertwea'lA n/'H/, tanAajel/e Office of Conskiew Malta&Business Regulation HOME IMPROVEMENT CONTRACTOR H TYRE:Individual . V724741 07/01/2020 ANDREI YARMALOUIC1* D/B/A BEL ISLANDS HOME IMPROVEMENT . ANDREI YARMALOVP `�-U II 204 CINDERELLA TER. MARSTONS MILLS,MA 02648 Undersecretary I 1 c. Commonwealth of Massachusetts Division of Professional L'censure �J Board of Building Regulations and Standards Conskp�rvisor , , rr CS-111305 ;,, !pires: 06/01/2021 ANDREYARMALOVICH"f ✓ 204 CINDEREL1,O TER i. MARSTONS MiLL,S MA 02648\� *. v Commissioner