HomeMy WebLinkAboutbld-23-002343 OV'Y.qR 0 a_�1i/_ j/— /,Z Z `Office Use Only y
. ,ti i,1O tf Permit# C #2 13 ef 1
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. H ,Amount 67),6d?nwrnc,-7
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Permit expires 180 days from -'
l issue date
60)- 23 - 0z3143
EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH [ RECEIVED
Yarmouth Building Department I - -___ -•_.
1146 Route 28 OCT 312022
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261 BUILDING GEPARI MENT
-- --
CONSTRUCTION ADDRESS: 4j 1 Capt.. /' /.f t y E.,1,
ASSESSOR'S INFORMATION:
Map: Parcel: I q
OWNER: h<< . ut t.1,I\ &uJ fY y1 Cif IZ P( ( 173 ` k 73 �56c
NAME PRESENT ADD SS TEL. #
CONTRACTOR: �`/"`t if(ix PrL/4 i4. Li /1 V o/c,.13 4 i'-r k N. Ye I t L--2 — 0 7 3 Y
NAME MAILING ADDRESS TEL.#
Residential ❑Commercial Est.Cost of Construction$ G.l C 00. 6
Home Improvement Contractor Lic.# / c t 3 t Construction Supervisor Lic.# C 5 j 13 ,0-7
Workman's Compensation Insurance: check one)
❑ I am the homeowner V am the sole proprietor ❑ 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 ( )Remove existing* (max.2 layers) Insulation
Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing
1 • I
*The debris will be disposed of at: \l(1 f Y11 G vI"L I S pt SJ
Location df 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 denial or revocation of my license and for prosecution under M.G.L.Ch.268,Section 1.
Applicant's Signature: J t 10. gliA.-...--'" Date: U(-� 31 16 ).
n / 2 r
Owners Signature(or attachment) `+ Date: L L r 31, 2 0 2 L.
Approved By: < — Date: /G` �3— <.
Building Official(or des' ee) EMAIL ADDRESS:
Zoning District: 5'h /1 lv n n-{—
Historical District: 0 Yes ❑ No Flood Plain Zone: 0 Yes ❑ No /`(
Water Resource Protection District: Within 100 ft.of Wetlands:
0 Yes 0 No 0 Yes 0 No 9 Y) Li - L 1 2- —
.4
The Commonwealth of Massachusetts
s+�r � Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
;5.•` 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): \3 7 c; 19,,-v h r we i
Address: .7) W,,.,s h,rt r
•
City/State/Zip?. ) e11•1, Phone #: Z i 3 Y
Are you an employer?Check the appropriate box:
Type of project(required):
1.0 I am a employer with employees(full and/or part-time).* 7. ❑New construction
2. vI am a sole proprietor or partnership and have no employees working for me in 8. 7 Remodeling
any capacity.[No workers'comp.insurance required.]
3. I am a homeowner doing all work myself. t 9. ❑ Demolition
❑ y [No workers'comp.insurance required.]
4.❑I am a homeowner and will be hiring contractors to conduct all work on property.mY
I will 10 Building addition
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.❑Roof repairs
These sub-contractors have employees and have workers'comp. insurance.$
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 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: L K P`/--, c>, i :9 City/State/Zip: 5 �Y"M c:
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: ,'i 9 At—'" Date: Ie 3/— Z Z.
Phone#: t y b / r! Z - C 13
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#:
I Mass.gov
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Business
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HIC Registration Complaints
Registration 194380
Registrant Stephen Pruneau
Name Stephen Pruneau
Address 15 North Main Street Apt. 2
City, State South Yarmouth, MA 02664
Zip
Expiration 01/30/2023
Date
Complaints Details
No complaints found for this registrant,
You can also view arbitration and Guaranty Fund history.
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