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EXPRESS BUILDING PERMIT APPLIC A S k
TOWN OF YARMOUTH RE
Yarmouth Building Department
1146 Route 28 APR 2 4 2023
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261 BUi DNBy
_
5 CONSTRUCTION ADDRESS: Danbury Street, South Yarmouth MA
ASSESSOR'S INFORMATION:
Map: 34 Parcel: 172
OWNER: Joe Cervone 5 Danbury Street 401-556-4957
NAME PRESENT ADDRESS TEL. #
CONTRACTOR: Alum Prod of CC PO Box 10 Dport MA 02639 508-398-8546
NAME MAILING ADDRESS TEL#
CI Residential 0 Commercial Est.Cost of Construction,p4000.00
Home Improvement Contractor Lie.# 158424 Construction Supervisor Lit.#C SSL-100160
Workman's Compensation Insurance: (check one)
0 I am the homeowner 0 I am the sole proprietor 0 I have Worker's Compensation Insurance
AIM Mutual Insurance WMZ-800-8006835-20.
Insurance Company Name: Worker's Comp.Policy#
WORK TO BE PERFORMED
Tent Duration (Fire Retardant Certificate attached?) Wood Stove
1
Siding: #of Squares Replacement windows:# Replacement doors: #
Roofing: #of Squares (Ti)Remove existing* (max.2 layers) Insulation ri
Old Kings Highway/Historic Dist. (0)Replacing like for like Pool fencing
*The debris will be disposed of at. 476 Main Street Dennisport MA 02639
Location of Facility
I declare under penalties of pet jury that e 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 Applicant's Signature: revocati of my license and_f_c_inr e tion under M.G.L.Ch.268,Section I
Date: 04/20/2023
Date: 4 0 /20/2023
Owners Signature(or attachment)
Approved By' Date:
EMAIL ADDRE Building Official(or
apofcc.com
zOrmhunter@ d ne
Zoning District:
I listorical District: Yes No Flood Plain Zone: Yes No
Water Resource Protection District: Within 100 ft.of Wetlands:
Yes ' No Yes No
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Commonwealth of Massachusetts
Division of Occupational Licensure
Board of Building Reoulations and Standards
t""lius,,,
Constructioolfroupoeviviir Specialty
CSSL-100160 4.4' , ,- e4pires:071'11/2024
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The Commonwealth of Massachusetts
1' 'il Department of Industrial Accidents
1 1 Congress Street, Suite 100
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): ALUMINUM PRODUCTS OF CAPE COD, INC
Address: 476 MAIN STREET
City/State/Zip:DENNISPORT, MA 02639 Phone#:508-398-8546
Are you an employer?Check the appropriate box:
Type of project(required):
1. ✓Q I am a employer with 14 employees(full and/or part-time).* 7. El New construction
2.0 I am a sole proprietor or partnership and have no employees working for me in 8. 0✓ Remodeling
any capacity.[No workers'comp.insurance required.]
3.0I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
9. ❑Demolition
10 Q Building addition
4.01 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 11.0 Electrical repairs or additions
proprietors with no employees.
12.❑Plumbing repairs or additions
5.a I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.1=IROOf 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:A.I.M. MUTUAL INSURANCE COMPANY
Policy#or Self-ins.Lic.#:WMZ-800-8006835-2022A Expiration Date:08/15/2023
Job Site Address: 5 DANBURY STREET City/State/Zip:S.YARMOUTH/MA
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 e ins and pen 'es perjury that the information provided above is true and correct.
Signature: .e6 Date: q--ZG — Z-
Phone#:508-398-8546
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#:
Owners Authorization Form
Town Of Yarmouth
1146 Route 28
South Yarmouth, MA 02664
Please print or type
Statement of ownership: I , Joe Cervone , state that I am the owner of
property located at _ 5 Danbury Street
South Yarmouth, MA
Authorization and address: I hereby authorize Aluminum Products of Cape Cod, Inc.to perform
work on my property at 5 Danbury Street
South Yarmouth, MA
Name of Authorized Agent/Contractor: Aluminum Products of Cape Cod, Inc.
Owners Signature:
Date : 2 D