HomeMy WebLinkAboutBLD-22-007388 �1 a//t ,[ _ '1 Office Use Only
.... C'-, R4 Permit C I it
X. ~ OC �Y 124/ iAmount ..00 i
G MATTACH CSE
�w,a.„L,° d Permit expires 180 days from
E i issue date
6 -Od 73':
EXPRESS BUILDING PERMIT APPLICATIM E C E 1 V E
TOWN OF YARMOUTH
Yarmouth Building Department JUN 2 02
1146 Route 28
South Yarmouth, MA 02664 BU PrnnENT
By:
(508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS: 25 qa vh h ci fe( VP
ASSESSOR'S INFORMATION:
Map: I, Parcel: p q
OWNER: I H V'i •J r1V'► g 5 S LADDibDL'WWLl t- 5 0 ESS TEL. #2-92- J�1.11
NAME C�// PRESENT
S h n c
CONTRACTOR: g6 I 7"- #Li y i7 `I 5 irzto er Biz- v 9i�'lk" / ',—9 a3NAME MAIL ADD SS TEL-.# !' 3/ „
P1 Residential ❑Commercial Est.Cost of Construction s5—IOC
Home Improvement Contractor Lic.# / 35 6 Construction Supervisor Lic.# 6 9 1 )/O ,
Workman''s—Compensation Insurance: (check one)
!rl 1 am the homeowner yI am the sole proprietor ❑ 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 Ji GI
Replacement windows:# Replacement doors: #
Roof g: #of Squares ( )Remove existing*(max.2 layers) Insulation
Old Kings Hi hwa /Historic ist. ( ee laci like f r like Pool fencing
*The debris will be disposed of at: rha n s kl-s kfien
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 revocatio f y license and for rosecution un r i G.L.Ch.268,Section 1.
Applicant's Signature: Date: G 6 — 2 2 2°Z 1 -
•
Owners Signature(or attachment) Date: dG ' 2? " 2072-
Approved By: Date:
Building i . or designee) EMAIL RESS:
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 E. No
r • '`� � The Commonwealth of Massachusetts
° 9.1
_.
/. Department of Industrial Accidents
_ _ 1 Congress Street, Suite 100
__ 1__ ' 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 q� Please Print Legibly
Name (Business/Organization/Individual): 1 1G1 U Vi1/H-
Address: 9--c- 1 5 .9 oirci,g, 4
•
City/State/Zip: Ee5ibn /ilk (2)2 Phone #: e 1 9'5- 311ei
Are you an employer?Check the appropriate box: Type of project(required):
1.D I am a employer with employees(full and/or part-time).* 7. 0 New construction
2.I 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.]
9. ❑ Demolition
` 3.0 I am a homeowner doing all work myself. [No workers'comp.insurance required.]t
10 0 Building addition
4.0 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.E Electrical repairs or additions
proprietors with no employees.
12.0 Plumbing repairs or additions
5.E I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.E Roof repairs
These sub-contractors have employees and have workers'comp.insurance.$
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c.
14.E Other Sid i 11 YQ fl a L P—
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. `C l II ''
Insurance Company Name: U LM IA 5 Cbo cykliC.fL lu'1
Policy#or Self-ins.Lic.#: ( 5 - 0 5.1 70 Expiration Date: 0-7 _ /S - 20 a-
Job Site Address: 9..-5 1 M i L,l /,ntq,4 M A- City/State/Zip: 0 6 7
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$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
1 do hereby certify and r the pains and penalties of perjury that the information provided above is true and correct.
Signature: Date: O 6 2 5 --Z(32.3 _
Phone#: -7$ I X5 -7-7
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#:
•
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Mass.gov
, Consumer
r-
(ocABR)
HIC Registration Complaints
Registration 135236
Registrant HOI T HUYNH
DBA HUYNH CONSTRUCTION
Name HOI HUYNH
Address 59 GRANGER ST.
City, State DORCHESTER, MA 02122
Zip
Expiration 03/14/2024
Date
Complaints Details
No complaints found for this registrant.
You can also view arbitration and Guaranty Fund history.
Doc: 1,449,715 01-12-2022 2 : 40
NOT NOT
AN AN
OFFICIAL OFFICIAL
COPY COPY
NOT NOT
AN AN
OFFICIAL OFFICIAL
COPY COPY
QUITCLAIM DEED
We,Thuy Truong,Individually of 32 Headwaters Drive, Yarmouth, MA 02673 and Son
Nguyen, an unmarried man of 1833 Daytona Drive, San Jose, CA 95122 by Thomas
Grimmer,as authorized signatory pursuant to a Judgment and Decree by Hon. Angela M.
o Ordonez dated June 25, 2020 and filed with Barnstable Probate and Family Court,
Docket No.BA16D0855DR,an attested copy of which is attached hereto as Exhibit A
For nominal consideration
Grant to
Thuy Truong,an unmarried woman of 32 Headwaters Drive,Yarmouth,MA 02673,
With Quitclaim Covenants,
The land together with the buildings thereon situated in the Town of Yarmouth (West),
Barnstable County,Massachusetts,being shown as:
at
LOT 45
•
Land Court Plan 30949-F(Sheet 2)
N
Subject to and with the benefit of all rights, reservations, easements and restrictions of •
record insofar as the same are in force and applicable.
Meaning and intending to convey the same premises conveyed to the Grantors by Deed
dated December 15,2004 and registered with the Barnstable County Registry of Deeds as
A: Document No.988,711 filed with Certificate of Title No. 175356.
Doc: 1,449,715 01-12-2022 2 : 40 Page 2 of 4
NOT tN�NOT
Witness TY a idel isII-day ofJ .bg a r V2' AL
COPY COPY •
NOT
AN
OFFICIAL 0 PI gI L
COPY COPY
COMMONWEALTH OF MASSACHUSETTS
Barnstable,ss.
ofthe undersigned notarypublic,
On this ?Jc�l It December 2021, before me, gn
personally appeared Thuy Truong, who proved to me througf satisfactory evidence of
identification which was [ ] Driver's License [• personally known to me [ ]
Other: to be the person whose name is signed on the preceding or attached
document and acknowledged to me that she signed it voluntarily for its stated purpose
and who swore or affirmed to me that the contents of this document are truthful and
accurate to the best of her knowledge and /14;64_,
Public: Robert F.Mills
My commission expires: 3/11/2022
(SEAL) 00wmu+p��
``„A F. mitts/
0. .A7622
1 I
1
•
Doc: 1,449,715 01-12-2022 2 : 40 Page 3 of 4
Witness my hand gic pail this 3u day of Decemtgr?)0211.
AN AN
OFFICIAL OFFICIAL
COPY t`PC O Gqivret
Son N �^ •
NOT By: IM. Grimmer •
AN •
s .TRIM.
ent and Decree
O F COPY A L Ord: - J �•s a 5121 OL
See I9ocQcetl'Na.BA16D0855DR
COMMONWEALTH OF MASSACHUSETTS
Barnstable, ss.
On this 3 d day of December 2021, before me, the undersigned notary public,
personally appeared Thomas M. Grimmer as authorized signatory for Son Nguyen
pursuant to a Judgment and Decree dated June 25, 2020 filed with Docket No.
BA16D0855DR,who proved to me tj d h satisfactory evidence of identification which
was [ ] Driver's License [ personally known to me [ ] Other: to be the
person whose name is signed on the preceding or attached document and acknowledged
to me that he signed it voluntarily, under Order of the Court, for its stated purpose and
who swore or affirmed to me that the contents of this document are truthful and accurate
to the best of his knowledge and belief.
atkiV4‘- AAA--
Notary Public: Robert F.Mills
My commission expires: 3/11/2022
(SEAL)
Doc: 1,449,715 01-12-2022 2 : 40 Page 4 of 4
0
�lMIONWEALTh OF MASSACI OUSTTS •
THE° F IFac ri ADLFAwlli Y co1,RIAL `rratiar , rt' •
COPY• _ COPY •
Barnstable Division Docket No.BA16D0855DR
N O T N O T
A N • A N •
O F F I C Pall ll�q % tiF C I A L
COPY •
v. C O P Y .
• SON V. NGUYEN,Defendant .
•
.= JUDGMENT
(Comolak,t for Confemot fed on 01,23r20)
•
After Zoom video `6i9for&tbe Coe . -25,2020 herebi the Plaintiff(Wife')
appeared and was represented by Afteincii T'f as-,trimmer and the Defendant.(`Husband')
failed to appear. Deferidei�! `sdi°led ' Def tdrta DF Ve;.S`erVASW, CA.95122. The Court
finds the Defendant GUILTY of contempt for failing to convey two properties, Headwater Pri►re,
• Yarmouth, MA. and 25 Bamboard Lane,West Yarmouth, MA:to Wife 3?.lay SepterrfbieiHS,
•
2018. It is hereby ordered as follows:
Wherefore,Attorney Thomas Grinimerks authorlred in Son V.Nguyen's name and stead
- to sign for the Husband all documents necessary to convey the two properties in the sole name
.of the Plaintiff. The legal effect of such signing shall be the same as if It were the free act and
deed of Son V. Nguyen.
June 25,2020
Ordofiez,Justice
ec Ally.Grimier 8.Muyen
•
•
• A TRUE COPY •
ATTEST .- . . .
REGISTER
•
•
•
•
JOHN F. MEADE, ASSISTANT RECORDER
BARNSTABLE REGISTRY LAND COURT DISTRICTS
RECEIVED & RECORDED ELECTRONICALLY