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Home My WebLink Aboutbld-20-4792 O .yqR Office Use Only . " 'Permit# .�If SO — 0 0 Amount wATr n s Permit expires 180 days from Q \ ` ` 9 issue date EXPRESS BUILDING PERMIT APPLICATION E. t E TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 ` l, South Yarmouth,MA 02664 (508)398-2231 Ext. 1261 _ 5� CONSTRUCTION ADDRESS: a9 l Cti r1 �.J ASSESSOR'S INFORMATION: Map: Parcel:OWNER: e_ED en- i IM> '''NAMEPR)SENT AD RES U1 4 r1 V e' ?\--4)c)b[-591- CONTRACTOR: lA (Ne r EhLING RESS 'v -/a ✓ 1 3 -71 91) 'B'Itesidential 0 Commercial Est.Cost of Construction$ Home Improvement Contractor Lic.# 1FM-1�� Construction Supervisor Lie.# I Workman's Compensation Insurance: (che one) I am the homeowner the sole proprietor E 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:# (p Replacement doors: # 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: [� � �a�^ r �C 1' t, •�S Q��a Loca'on of Facility `� I declare under penalties of perju at 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 v of my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: x Date: l l r C_iy-\ At a Owners Signature(or attach nt) t Date: 4 " h 3, .G C3 c Approved By: Date: 3 - ,. Building Official(or designee EMAIL ADDRESS: Zoning District: Historical District: Yes "i No Flood Plain Zone: 7 Yes IL No Water Resource Protection District: Within 100 ft.of Wetlands: Yes Ll No Yes ❑ No • The Commonwealth of Massachusetts A/ Department of Industrial Accidents 11". ::il11= 1 Congress Street,Suite 100 • c`a�_I= 4 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): J e�� (_7., -ne Address: C3 t-‘, Ave City/State/Zip: [A). g acrYkm- MR Phone#: ISO&—�`�`-t-- t Are you an employer?Check the appropriate box: Type of project(required): l.❑I am a employer with employees(full and/or part-time).* 7. ❑New construction 2. 1 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 Ei 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 5.0 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.: 6.p We are a corporation and its officers have exercised their right of exemption per MGL c. 14.El Other 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: 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. - i cation. I do it:,eby certify under t e pains and pens of perjury that the information provided above is true and correct Sign.' e: Date: ..` 7 C-")_C) Phone#: 1' a-3 - 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#: Q97L /QooacAaoe/ Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Individual JAMES CZARNECKI Registration: 184167 Expiration: 12/16/2021 8 HASTINGS AVE WEST YARMOUTH,MA 02673 Update Address and Return Card. SCA 1 0 20M-05/17 rJ,h*ommorra'na///ty9"hiajacktsef6 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: Registration Expiration Office of Consumer Affairs and Business Regulation 184167 12/16/2021 1000 W • on -Suite 710 JAMES CZARNECKI Boston,MA 02118 2 L../ �V JAMES CZARNECKI 8 HASTINGS AVE .r..ef a.i WEST YARMOUTH,MA 02673 Undersecretary of valid without signature • r I. —______„ Commonwealth of Massachusetts 111 Division of Professional Licensure Board of Building Regulations and Standards ConstruttibIY i pprvisor CS-089214 rApires:12/17/2021 JAMES B CZARNECKI,: a r 8 BASTING AVE 4 WEST YARMOUTH MA 02673 -- t • Commissioner A,(,i,,,,c)►/��0 1