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EXPRESS BUILDING PERMIT APPLICATIOR E D E I V E D
TOWN OF YARMOUTH
Yarmouth Building Department SEP 12 2022
1146 Route 28
South Yarmouth, MA 02664 BUILDING DEPARTMENT
(508) 398-2231 Ext. 1261 By
CONSTRUCTION ADDRESS: ct 7 If 1 D le_ el-7 c -0 L-¢2, '14e-yam/3 / ,4yy�. a 2-C 4 y
ASSESSOR'S INFORMATION:
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Map: Parcel:
OWNER: //cub Znx Ci cure -2 LI VI d lam' /en i'Cc
NAME PRESENT ADDRESS / TEL. #
CONTRACTOR: •/ Zr, l�/�n-i P,�J/1) 7 0Gi kwr. ail &CS'Y"/ a' 4 �Dg) ?2-. —Z 5 /
NAME �/ MAILING ADDRESS TEL.# y� ,r�g Residential ❑Commercial Est.Cost of Construction$ �V_, OdM.AO
Home Improvement Contractor Lic.# /4/L/4.4 Construction Supervisor Lic.# O Fzs L.9
Workman's Compensation Insurance: (check one)
0 I am the homeowner ,2(I 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 /6 Replacement windows:# 5 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: &oti,V f/(,L (Ali pl 6//
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 revocati f my license and for prosecution under M.G.L.Ch.268,Section 1.
Applicant's Signature: Date: ei 1114Zi.
Owners Signature(or attachment) _ ( [ 1 l L/Z L
�� _Date:
Approved By: ,. y► 1�
Building ODate: ����
b c "-sic, ee) EMAIL IPS.9 i SS:
cew e GdN^Cksk Ile-4--
Zoning District:
Historical District: 0 Yes 0 No Flood Plain Zone: ❑ Yes 0 No
Water Resource Protection District: Within 100 ft.of Wetlands:
0 Yes 0 No 0 Yes ❑ No
• The Commonwealth of Massachusetts
t Department of Industrial Accidents
ft 111/ 1 Congress Street, Suite 100
Boston, MA 02114-2017
.11 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): $If c/7 7T
Address: I &I
City/State/Zip: I4d5� J .41L 6 Vy Phone #: �S ) ZL - Z.S'G/
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. El New construction
2.it I am a sole proprietor or partnership and have no employees working for me in
• any capacity.[No workers'comp.insurance required.] 8• Remodeling
3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]uired. 9. l-J Demolition
4.E I am a homeowner and will be hiring contractors to conduct all work on mYProPnY•
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.
5.[]I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 12.0 Plumbing repairs or additions
These sub-contractors have employees and have workers'comp.insurance.1 13.0 Roof repairs
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.0 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:
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 pains and penalties of perjury that the information provided above is true and correct.
Signature:
Date:
Phone#: (5'6 ) F 2-4 ZSZ
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#:
THE COMMONWEALTH OF MASSACHUSETTS
Office of Consumer A &Business Regulation
HOME IMPROV ONTRACTOR
BASIL CONGRO 64
D/B/A CONGRO
BASIL J.CONGRO
7 DANA RD. ,
FORESTDALE,MA 02644.
Undersecretary
lo Commonwealth of Massachusetts
Division of Occupational Licensure
' fi Board of Building Re ulations and Standards
Cons ioonwisor
CS-082529 r r pires: 12/10/2023
BASIL J CO Rt ,'Ill -"
7 DANA ROAD IoNy O
FORESTDALtM
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