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Home My WebLink AboutBLD-23-001575 `.:''01..Y`1R Office Use Only y ` Permit# s '�l 0 . .. . y Amount /DO •V v '? MATTACn [S[J��, Permit expires 180 days from !issue date IVED EXPRESS BUILDING PERMIT APPLICATI14 = F TOWN OF YARMOUTH - - --- Yarmouth Building Department r SEP 2 6 2022 1146 Route 28 South Yarmouth, MA 02664 BUI i.__ r�r EIi (508) 398-2231 Ext. 1261 By CONSTRUCTION ADDRESS: 3 sL w,r'1 b/ Ch,Al ,3CJb-2-3-CV S ASSESSOR'S INFORMATION: Map: Parcel: OWNER: ieim, r►imtt. C jel4..IN 3), U)lv►bie s'Qfr- C 54 GI 13 11 NAME / PRESENT ADDRESS TEL. # CONTRACTOR: %T lyl.I I . 24 r 4.,& q?-s--- ,s- .S-,y.23 S c.) NAME MAILING ADDRESS TEL.# c.c. Tdential 0 Commercial '�f, Est.Cost of Construction$ /S covv Home Improvement Contractor Lic.# /45 a ` A-Construction Supervisor Lic.# CS &175"3 (,I/ Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor aI have Worker's Compensation Insurance Insurance Company Name: /tAT-J ''`-5 Worker's Comp.Policy# QI f{GUs'o3 116 3 7/.7 WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows: # 6 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 c1u..._ 64,C4 iI 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 pr ecut n under M.G.L.Ch.268,Section I. Applicant's Signature: /7 Date: f ')0a.L Owners Signature(or attachment) e---\ 6418.e + . Date: 9`,c`.,&& 7., Approved By: Date: ---,2- — '2_ Building Official(or deli e IAIL 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 ❑ No y►- 1 '� The Common wealth of Massachusetts _W, Department of Industrial Accidents _T/►11= 1 Congress Street, Suite 100 =\Iti...,�< Boston, MA 02114-2017 • s.•'• 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): 4/�. ea4,4*-r 5 Address: 9 d Sr- d -- . City/State/Zip: 64,,c S 674.6.4^-..„ Phone #: S7`/ ,)3 S" Are you an employer?Check the appropriate box: Type of project(required): 1. Err--am a employer with / 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. ❑ Remodeling any capacity.[No workers'comp.insurance required.] 3. I am a homeowner doing all work myself. [No workers'comp. insurance required.]1' 9. ❑ Demolition 4.0 I am a homeowner and will be hiring contractors to conduct all work on m Y property. 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.El 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. r 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: /l- ‘9n S Policy#or Self-ins. Lic. #: 0/Y 2 SC' el6 •7/a ( Expiration Date: S/ a 3 Job Site Address: 3 1A im ble._ U/./ City/State/Zip: ail 5 ' 1.4 ‘ 4,74'73 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 f perjury that the information provided above is true and correct. Signature: Date: %'�6 'J�� - Phone#: 5c>.0 fir/ D . S4) 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#: Fallon, Rosa From: TOM NICKINELLO <tenick@aol.com> Sent: Monday, September 26, 2022 9:51 AM To: Fallon, Rosa Subject: 32 Wimbledon Attention!:This email originates outside of the organization. Do not open attachments or click links unless you are sure this email is from a known sender and you know the content is safe. Call the sender to verify if unsure. Otherwise delete this email. NE C01MIOwwEwn4 os II49sACiAJSETT3 oAi i Of Consumer Affairs i 1344.1i4P64 Favviasen MOTE aroo£AEMTGOXTFAACTOA TTAE caGors.c t39998 D.2 2024 TNT F,raenrE"1'ER .,%c, TOM MOW Q sis ROUTE 28 i .� . SOUTH YAR IOUN iAm 82664 Undersecretary As always,Thanks Tom 1 Fallon, Rosa From: TOM NICKINELLO <tenick@aol.com> Sent: Monday, September 26, 2022 9:49 AM To: Fallon, Rosa Subject: 32 Wimbledon Attention!:This email originates outside of the organization. Do not open attachments or click links unless you are sure this email is from a known sender and you know the content is safe. Call the sender to verify if unsure. Otherwise delete this email. Massachiusetts Division ,* Ltrensure Board of sidin uons and standards, Cons icim isor 017539 6/ires: 06/0512()24 THOMAS K *44 928 ROUTE SOUTH A U Vic/ w Corritnlss .,� As always,Thanks Tom