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Home My WebLink AboutBld-20-002650 1 Office Use Only �! Permit# 0 1 ',!� Hi ':Amount � i !°�*\°....,0,0 c`�a.' 1Permit expires 180 days from i issue date •,... EXPRESS BUILDING PERMIT APPLICAT C - ,-.� AN ..f ._�w_. .. : TOWN OF YARMOUTH ' NtlV ') ' U1" Yarmouth Building Department 1146 Route 28 _$F South Yarmouth, MA 02664 (508)V / 98 398-2231 Ext. 1261�„ C car, CONSTRUCTION ADDRESS: 2 5 e- •. f k �`-"S . JO --1L 1 / ,R frt D t, `f l ASSESSOR'S INFORMATION: �7 Map: Parcel: OWNER: De*"/ r,-, /i.0_ C• NAME PRESENTn ADDRESS TEL. # CONTRACTOR: / /L 24 ci6 Yr7 F-� 4 7-- c-o 4 cA NAME MAILING ADDRESS TEL.# Lf Residential ❑Commercial Est.Cost of Construction$ 2 2 .90 0 Home Improvement Contractor Lic.# / 9" 2. Construction Supervisor Lic.# 1! f 3 2 Workman's Compensation Insurance: (check one) ❑ I am the homeowner ❑ I am the sole propri tor I have Worker's Compensation Insurance ems+/' Insurance Company Name: L L / �kWorker's Comp.Policy#W( —/S / 15 66---0/3 WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove te Siding: #of Squares Replacement windows: # p Replacement doors: # O.- — 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: /' Ap vC ..... Location of Facility V I declare under penalties of perjury that the ents herein conta' are tnie and correct to the best of my knowledge and belief. I understand that any false answer(s) will be just cause for denial or rev tion y license and for se ution under M.G.L.Ch.268,Section 1. Applicant's Signature: f d Date: ///DY W`i / Owners Signature(or atta Date: </ 12 /24Cilic. Approved By: Date: /! --�.1. Building Official(or gn EMAIL ADD . Zoning District: Historical District: 0 Yes D No Flood Plain Zone: ❑ Yes rii No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes No The Commonwealth of Massachusetts ' Department oflndustrialAccidents 1 Congress Street, Suite 100 �i I )712 T Boston, MA 02114-2017 °,,imps www.mass.gov/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): r Yoaref'?�-cx),,//v4 Address:y '1dL e_a C . City/State/Zip:/'�� 4 t G1(i.j/s Phone #: P - TO ,-J 1tr Are yo n employer?Check theem appropriate box: Type of project(required): I. I am a employer with yees(full and/or part-time).* 7. _ New construction 2.E]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. D 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 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp. insurance. 13.❑Roof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.E 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: 4fry-042c , `/J.' -mil /ii . Policy#or Self-ins. Lic. #: I.t It 5_ 3/S'/ 3— — DC Expiration Date: / L /AveJob Site Address: 2 C VI1 -L-- /2 L I ^ c City/State/Zip: vi..,o,,0) 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 ,. statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify u I- the p y s and penalti s of perjury that the information provided above is true and correct. Signature: �Date: / (X �s�' Phone#: dD 9- 220 l '/' L 7 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#: �%hn` ninrxc i+raeaid nrn/,sj(rrlrisv!!s o!floo of Consignor Maks&SwainarRogulation HOME IMPROVEMENT CONTRACTOR TYPE:Individual 07/01/2020 ANDREI YARMALOUID1 IMPROVEMENT D/B/A BEL ISLANDS . ANDREI YARMALOVVM d-"6""1 204 CINDERELLA TER. MARSTONS MILLS,MA 02648 Undersecretary Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Constrtri�t.lp,^rvisor CS-111305 °:1 4,pires: 06/01/2021 i r. ANDRE YARMALOVICHR ✓ i 7 '6`; 204 CINDERELL,O TERRACE MARSTONS MILLS MA 02648�` Commissioner