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Home My WebLink AboutBLD-23-001311 ^f gY,gR / " tti t dig 11 p L' q 1 I c/Z;� :'Office Use Only /�/�y� , C ( tor— bt RECEIVED Permit# f ��UIY lI �_L 1---_- _....._.._._ .Amount �v ��,\ATTACH CSC„4t ...0a t•Q SEP 1 2 22 !Permit expires 180 days from CI issue date BUILDING DEPARTMENT ,LLD .23 .00131 f EXPRESS BUILDING PE N TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: I 2_ Shct do 2,-eSf— I)r c u ASSESSOR'S INFORMATION: l Map: Parcel: / OWNER: (�c.f t•�.l 192 ) S cH r"1 i6 ( - ( Z se-t4ny12 657 (3/2 NAME PRESENT ADDRESS TEL. # CONTRACTOR: 4 le l2 V(3 y ( O s If 40,x (2 cts v)/2. ce)7 -7?C ( 53 NAME MAILING ADDRESS TEL.# PJ Residential 0 Commercial Est.Cost of Construction$ "7 6 (v - _ v - Home Improvement Contractor Lic.# 11 O C I Z Construction Supervisor Lic.# C-S-O6S (`'(c( Workman's Compensation Insurance: k one) ❑ I am the homeowner 'I am the sole proprietor ❑ I have Worker's Compensation Insurance • Insurance Company Name: .. or n h i! Sc, L( i✓..1.A., Worker's Comp.Policy# WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:#_0_ Replacement doors: # Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. (Replacing like for like Pool fencing ( X16' o.Q rtRi *The debris will be disposed of at: V A 2 ill 0%,./T'N 1— i-,--) F- 1 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 revocation of my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: ( Date: ( (Z. I Z Z Owners Signatu (or attachment) I Date: Approved By: Date: Building Official(or ,ne EMAIL ADDRESS: Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes ❑ No 1 The Commonwealth of Massachusetts - _`_, /, Department of Industrial Accidents 1 Congress Street, Suite 100 7. 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): pl 4 Z IC (2-t3 y Address: r 6 rS S n 0,, City/State/Zip: S, �Coi 0,7 i • Phone #: �� 7�6 / 6-3a Are you an employer?Check the appropriate box: Type of project(required): I.Dyarn a employer with employees(full and/or part-time).* 7. ❑ New construction 2 I am a sole proprietor or partnership and have no employees working for me in 8. 24-.emodeling any capacity.[No workers'comp.insurance required.] 9. ❑ Demolition 3.❑I am a homeowner doing all work myself. [No workers'comp.insurance required.]t _ 10 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.Q 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. 14.0 Other (5�-I k Z vs/ 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. tContractors 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: 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 certify under the ains and penalties of perjury that the information provided above is true'and correct. Sitrnature: 'V Date: CC ( Z f L C Phone#: 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#: A • t 1 -.T\7 ./At I Ck.k) l' kPC12-k \Roy _ J • 1 � � raor ulation pftice of Consumer Affairs&Business Rag HOME IMPR Individual RACTOR n /60 MARK RUBY .(jpDELING C /� ( `fit I; DBIAMARKR�1'=iii. V /�� J Vi 1�� i MARKP.RUBY ;\_",,y/ ` 'C :J��i v� >//n\l�I"v(3`1/1�SHADY REST DR<r'-"=26ii4 Undersecretary 18 SH SOUTH YARMOUTH,MA � - Commonwealth of Massachusetts Division of Professional Licensure Board of Building Re ulatiioAnssaand Standards Consti t � ' isor CS-065149 . , ,pires:08/0412023 MARK RUBY- ?" , EJ , 18 SHADY RE)T D- HID 1 SOUTH YARI U 1 . • Commissioner caefla K. bjEnatO1— 2 Mass.gov Ornce corisumo I to r (OCABR) HIC Registration Complaints Registration # 178512 Registrant MARK RUBY DBA MARK RUBY BUILINGD & REMODLEING Name MARK RUBY Address 18 SHADY REST DR. City, State Zip SOUTH YARMOUTH, MA 02664 Expiration 04/21/2024 Date Complaints Details No complaints found for this registrant. You can also view arbitration and Guaranty Fund history. 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