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Home My WebLink Aboutbld-20-004263 AYH _ � Umce use unsy O R _, ;; • 11 �; 'Permit# I� ' .(per 'h H l Amount V ` MATTAcm CSA ! p days �`°°•.•«<•'' d'' Permit expires 180 da s from - ;.= i issue date EXPRESS BUILDING PERMIT APPLICATION _ TOWN OF YARMOUTH 1 E C E 1 V E D Yarmouth Building Department 1146 Route 28 1 • South Yarmouth, MA 02664 ; rFg 6 � ' (508) 398-2231 Ext. 1261 .2 .,,i XCONSTRUCTION ADDRESS: pi- zo 32 idl.A( *0 'I (i__ ILBaytr!yie------ro,f5-----. v_tv4 ASSESSOR'S INFORMATION: Map: Parcel: OWNER: E V VA-A,Cft 14 Z '7L-(1 L I S7 NAME PRESENT ADDRESS �� 7 TEL. # . 0ig.)Q CONTRACTOR: rr� MAILINGAD SS w r �TVE,L.# 4 NAN❑Residential ,(Commercial Est.Cost of Construction$ 1, Home Improvement Contractor Lic.# '3l fill Construction Supervisor Lic.# ^ 0 d 6 2.1 co Workman's Compensation Insurance: (check one) 7.3 I am the homeowner 11 I am the sole proprietor I have Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy# WORK TO BE PERFORMED Olc.- t Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows: # Replacement doors: # Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fe ing � CV �r71764l24(4AJ wt -� *The debris will be disposed of at: `t' u i. vi- Locati n of Facility I declare under penalties of perjury that the statements herein contained e 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 revo .tion of my license d fgr prosecu[ian under M.G.L.Ch.268,Section 1. J /!` Ni^� I ) / Applicant's Signature: f *� �, VV' 4 V Date: b L ) / 7122-� Owners Signature(or attachment) 'fti ,--Th Date: l/ )�((( Approved By: al- " it -AO PP �� Date: Building Offi . ; designee) EMAIL ADDRESS: Zoning District: Historical District: ❑ Yes No Flood Plain Zone: E Yes No Water Resource Protection District: Within 100 ft.of Wetlands: D Yes E No ❑ Yes ❑ No t '"\ The Commonwealth of Massachusetts Department oflndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 0,Ar i 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): I.AOUDGA 0 & n-R 7/ p-r'/ Address: I 0 I1-7191-67195 V,14)71 City/State/Zip: v-YID A( A F4,1 -02I 7/ Phone # , gej•- --(---N -f Are you n employer?Check the appropriate box: Type of project(required): l. I am a employer with employees(full and/or part-time).* 7. New construction n 2. I am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling any 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 41.E1 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.E Electrical repairs or additions proprietors with no employees. 12.E 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 6.E We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other— H Q 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. 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: 'TMV 1. C,t jc P Policy 4 or Self-ins. Lic. m: 6 11 )6— I 0 d D —1 01 Expiration Date: c % //z 0 273 Job Site Address: 321 MAN il. W , \M-gt-4ot1fA 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 c tify under the pains dpenalties of perjury that the information provided above is true and correct. Signature• �� `E" f1 M Date: Z/3 Z 0 IC/ Phone 4: 2 7'7@,e f Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License 4 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 Board of Building Regulations and Standards Construdtion'Supervisor CS-066290 Expires:07/12/2021 GEORGE MOUDOURIS..f 12 ATHENS WAY WEST YARMOUTH MA 02673 Commissioner ..,��/ TIP Kaminenroea�/,offeez„.i...kzcZAsehtt Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR , TYPE:Corporation Registratiot1 Expiration t398t1 .. ..- 08/24/2021 MOUDOURIS CONSTRUCTION INC • GEORGE M.MOUDOURIS, %�. 12 ATHENS WAY W.YARMOUTH,MA 02673 Undersecretary