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Home My WebLink AboutBLD-23-002105 01',yAR I .I Office Use Only /�/�� pp 4 l q flU /D / / / //� I Permit* ( '7?L A O Ou' _ D y Amount / 4 �) C ATTAcn LSE °'°"°"'`'e:d 'Permit expires 180 days from issue date QI D-a.3-66a/45 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department EVED 1146 Route 28 R E C I South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 OCT 19 2022 CONSTRUCTION ADDRESS: 1 T. 0 `O of k, A BUILDING DEPARTMENT ar _------ ASSESSOR'S INFORMATION: Map: Parcel: OWNER: TOIiiCt ISSi Iva • NAME PRESENT ADDRESS TEL. # CONTRACTOR: 8 Cali/i'J A/) i t O 1q d 124 0 w,i.) i 02660 17 26 8-0206 NAME MAILING ADDRESS TEL.# ❑Residential c14 Commercial Est.Cost of Construction$ /500 Home Improvement Contractor Lic.# t .4 001 Construction Supervisor Lic.# CS- /10 5 q 6 Workman's Compensation Insurance: (check one) 0 I am the homeowner BSI am the sole proprietor 0 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 *The debris will be disposed of at: T cif,ry10 b , Trani?,P, J 1"ef 0/l 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 denial or revoca'on of my license and for prosecution under M.G.L.Ch.268,Section 1. pp Applicant's Signature: / Date: 10 /qie Z Owners Signature(or attachment) Date: Approved By: /0, Date: ' —/9-<- Building Official( esi e) EMAIL ADDRES Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes ❑ No . ''\ The Commonwealth of Massachusetts �,►ate / Department of Industrial Accidents _ igiliST _�r; _ 1 Congress Street, Suite 100 • _�a•�= 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): 6 rau I O !5 I. t9 Address: ( S G l G L City/State/Zip: D eI,A,A6 Mrs cj?L,c10 Phone #: -11 N- - O2O C Are you an employer?Check the appropriate box: Type of project (required): l.ri I am a employer with employees(full and/or part-time).* 7. ❑ New construction 2g I am a sole proprietor or partnership and have no employees working for me in 8. E 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.]` 4.❑I am a homeowner and will be hiring contractors to conduct all work on mYProPrtY e I will 10 Building addition . ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.n Plumbing repairs or additions 5.11 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.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q 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: 13 1 fa ZO City/State/Zip: i 6.,,,r rwr)U 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 pains and penalties of perjury that the information provided above is true and correct. Signature: r K 71 Date: IO-- 1 q- ZZ, Phone#: 11 - 0 2 0 C 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#: September 14,2022 Agreement General Contractor: Braulio Brito Home Owner:Jenia DaSilva Property Address: 737 Rt. 28 REAR, South Yarmouth, MA 02664 Project: Exterior Back Door Installation Approximate cost: $2000 Signature:Jenia DaSilva ?41,i,GL ba-R&. WV- Signature: Braulio Brito --- commonwealth of Massachusetts Division o Occupational Licensure - , , -, , , iii.,_ , , Board of Building Re ut isorlations and Standards Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Can +on TYPE: Individual CS 110548 E;crp+ es:05/23t224. R@ s 8L 1 Expiration BRAULIO roITO 1 iJC+1 0214 02 19 SAGA ROAD °. , CS SOUTH DENNIS MA 0.13A B ABO SROTO l �` 0.3 A SSFiiTO SERVICES .e- ' t. BRAULIO BRITO Coln nissic.nc: (f� /1. V IE 19 SAGA RD 4'° , k SOUTH DENNIS,MA 02660 Undersecretary _ Commisstoner ,;. V fj ,.. -< _.�� .„ s _;