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HomeMy WebLinkAboutbld-23-003686 „„'' O�..Y,gR Office Use Only ,c-: . f .rr! ;Permit# Q Amount ce ATTACH Cs['r,� t °"”'° AQ e 1 Permit expires 180 days from l issue date RECEIVED . ---� ' SS BUILDING PERMIT APPLICATION BAN 0 6 2023 TOWN OF YARMOUTH _ _ Yarmouth Building Department BUILDING DEPARTMENT 1146 Route 28 (3(t.-z;,-3_(bS4), BY'-------- South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: C;(,t) p� a ---it (� ) . �'�f,ii\ok.1I,-, A 1 �itodt) IV ASSESSOR'S INFORMATION: Map: Parcel: • OWNER: ! L-dPJ! r!�}k4.r.� Ili' 'rZ i (2 ' en,t\.7 L:",k) f- ` --.'(tj . (i•.S i 8 `` '7L' 8--uo NAME I h PRESENT ADDRESS Vi Ff �."1;-.-( W TEL. # /o �7 ry CONTRACTORI6Zn IN 6 Z fte'1., 1✓ -1 W l IC if Ih ) J 1"r/ r cc�� t ti-9— 7 ( l( NAME MAILING ADDRESS TEL.# ❑Residential Commercial Est.Cost of Construction$ a• es-----es Home Improvement Contractor Lic.# 15181©l I C struction Supervisor Lic.# Z— >^Ot . - 1 0 Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor I have Worker's Compensation Insurance Insurance Company Name: [ Worker's Comp.Policy# � r1v �htrh ;' rhf�,�t-c,� Dcwio Hens Aee,c»., li-(4•+.��1 it;.le f.3h1-1.,< S Cr.,'C �"I I. ' WORK TO BE PERFORMED Di' O Tent Duration (Fire Retardant Certificate attached?) Wood Stove At - 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 fencing *The debris will be-disposed of at: I✓v M v. to F i -'R_ `,d 1 V i- 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 deni revocation of my livens an for pro, c 'on under M.G.L.Ch.268,Section 1. :-1 -�- / --- CI —2—Ai 2'1 Applicant's Signature: \\ Date: �/ y Owners Signature(or attachment) �., I Date: /` T — �7( 3 Approved By: Date: ,. '6',A) Building Official(or designee) EMAIL ADDRESS: Zoning District: Historical District: 0 Yes ❑ No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No "— '� The Commonwealth of Massachusetts Department of Industrial Accidents teilijkiP---r� 1 Congress Street, Suite 100 =r= Boston, MA 02114-2017 = www.mass.oov/dia Sv 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` ;II ( (J14 Address: r City/State/Zip:IL _ 'ivll1LCL i/f I-I t-' '7/ Phone #: (' F F'( ,. ( ' Cj ` ( Are yo an employer?Check the appropriate box: Type of project (required): 1. I am a employer with ; employees(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.] 3. I am a homeowner doing all work myself. 9. Demolition ❑ y (No workers'comp. insurance required.]I. l0 ❑ 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. 13.Q Roof repairs These sub-contractors have employees and have workers'comp. insurance.t 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.El 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: Policy#or Self-ins. Lic. #: '' /, �2-_ C C � 1 �1 i✓ Expiration Date: Job Site Address: (3 IL `{ ( V '7 Z_. ') City/State/Zip: \,N4, ( 6 g L' 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$250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pans an penalties of perjury that the information provided above is true and correct. Signature:l/—' }"'' Date: Phone#: e ; 7 Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License# Issuing Authority (circle one): 1. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: . The Commonwealth of Massachusetts t OM=el Department of Industa-ialAccjdents his `'- a�ii . 1 Congress Street, Suite 100 "� i Boston, 02 t I¢z(JI7 T.. F ,p 'ow vv WWW.mas govfdia Workers' Compensation Insurance Affidavit: guilders/ContractorsfElectricians/Plumbers. TO BE PILED WITH THE PERMITTING AUTEORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): Moudouris Construction, inc Address: 12 Athens Way City/State/Zip: West Yarmouth, MA 02673 Phone ; 50$_778 4586 Are you an employer?Check the appropriate box: Type of project (required): 1.173 I am a employer with 4 employees(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. al Remodeling any capacity,[No workers'comp. insurance required.) 3 I am a homeowner doingall work 9. ❑ Demolition ❑ myself No workers'camp.insurance required.)t 4. I am a homeowner and will be hiringcontractors to conduct all work on 10 ❑ Building addition ❑ my property, I will ensure that all contractors either have workers'compensation insurance or are sale 11.❑Electrical repairs or additions proprietors with no employees, 12.0 Plumbing repairs or additions 5.11 I am a general contractor and I have hired the stilreo:rtractors listed on the attached sheet_ 13. Roof repairs These sub-contractors have employees and have workers'comp.inured cc.1. ❑ 6.E]We area corporation and its officers haveright of atzrrrption Per MCxI e.exercised their ri I�4.❑Other . 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box*I 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. 2Contreetnrs that cheek this box must attached an additional sheet showing the dame of the sub-contractors and state whether or tot 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: Travelers Policy#or Self-ins.Lic.# UB 2E211009 Expiration Date. Job Site Address: 668 Main St(Rt 28) City/State/Zip: W.Yarrnouth, MA 02673 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 is true and correct. Signature:% Moudouris Construction, Inc Date: 12127/2022 ?/tone#_ 508-778-4586 Official use only. Do not write in this area,to be r_omptered by city or town official. City or Town: PermitfLicense# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3.Cityfrowa Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person:_ _ Phone#: - ••••• _ . . . • revnere".72&eagife›,../eexi,k7,^4,-;,,),-/-4, Office of Consumer Affairs&Business Reguiation HOMEAMPROYEMENT CONTRACTOR TYPE:Corporation Registeation liation 139811 ,08/24/2023 MOUDOURIS CONSTRUCTION INC GEORGE M.MOUDOURIS • 12 ATHENS WAY• • eA4ef ix/4.4 . VV.YARMOUTH,MA 02673 Undersecretary • s." Commonwealth of Massachusetts dr Division of Professional Licensure Board of Building Regulations and Standards • constspOrAiii6i.lpFv' isor GEORGE m :'..4•''''ctut11:: CS-066290 res:07/12/2023 613,: 12 ATHENS WY I :6 •WEST YARMINTH / • 14)/sii..1(A • it 4; Commissioner d _ A. -- - -