HomeMy WebLinkAboutBLD-22-007333 gp+Cp puceUOyygr:;z4
RECEIVED
Q 'Permit# 66 1 3q,
t4t'il
► - , JUN 212022 Amount
4.,,.,,,d`{ C IC L Permit expires 180 days from
BUILDING DEPART ENT issue date
eY _ — -- — 5 CD- Z2 -00733_3
EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth,MA 02664
(508)398-2231 Ext. 1261
CONSTRUCTION ADDRESS: ; L( fc r(9 ,4 L "- t,
ASSESSOR'S INFORMATION:
Map: Parcel:
-- S,Y,L
OWNER: •1=�1 I>--n 6,,,,c,I✓., • , .I o trLt` . - 77LI "1E7- /5 �
NAME _ s%silt' SS TEL. #
CONTRACTOR: West Dennis,q MA 02670 ( 6 ) a" LOG Y
NAME ( L h-6964 TEL.#
❑Residential 0 Commercial CSL f7' 33 HIC S - 9t3Construction$ 1)_''
,
Home Improvement Contractor Lic.# )(:J`1 V7Z, Construction Supervisor Lic.# LS4.:-
Workman's Compensation Insurance: (check one)
I am the homeowner L I am the sole proprietor EV(have Worker's Compensation Insurance
Insurance Company Name: I) -., I 1,1>i 1 + } t it fir-:) Worker's Comp.Policy# 1)5 W L t✓.;.3 1
WORK TO BE PERFORMED
Tent Duration (Fire Retardant Certificate attached?) Wood Stove
Siding: #of Squares Replacement windows:# 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: + e 1LC c
Location of Facility
I declare under penalties of perjury th
// t 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%ye( y license and for prosecution under M.G.L.Ch.268,Section I. ff
Applicant's Signature: v/ Date: al-I 7
Owners Signature(or attachment)/ , l.: 1.J-- Date: r;h.,1,>
Approved By: Date:
Building Official(or designee) EMAIL ADDRESS:
Zoning District:
Historical District: 11 Yes _' No Flood Plain Zone: 'Li Yes '._ No
Water Resource Protection District: Within 100 ft.of Wetlands:
Yes _i No Yes _. No e, (0 ,,,I,..,,,'_ I
L (6-8.0
Permit Authorization
1311
MSS • Form
simms&rout**tmergy
Site ID: 3822318 Customer: Edilson Goncalves
gdt, I sok Gx‘c•Av a S ,owner of the property located at:
(Owner's Name,printed)
24 Reid Avenue West Yarmouth, MA 02673
(Property Street Address) (City)
hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed
below to act on my behalf and obtain a building permit to perform insulation and/or weatherization
work on my property.
.1!0 >
Owner's Signature: /tail%
Date: 412.-4/2
FOR OFFICE USE ONLY
We have assigned the following Mass Save Home Energy Services Participating Contractor to the
above referenced project:
Participating Contractor Date
Name: RISE Engineering
Phone: 508-568-1926
Email:
Page 1 of 1 For Office Use Only
•
The Commonwealth of Massachusetts
1' _'/ Department of Industrial Accidents
•
-• 1 Congress Street,Suite 100
�- - • Boston,MA 02114-2017 • •
.�, •' www.massgovidia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTINGAUTHORITY. •
Analicant Information . • Please Print LRdibly
.Make M--C artily.OnlOwsia:tiv. r .
Name(Business/Organization/Individual): PO Box 52
Address: West Dennis, MA 02670
• • Cell (508)-280-6964. • � .
•
City/State/Zip: °�!"i a ez-Y : CSL-58f*ne SIC-169393 •
•
Are you an employer?Check the appropriate box: • Type of project(required):
•
1.�am a employed with 1� employees(full and/or part-time).*
7. El New construction
2.0I am a sole"proprietor or partnership and have no employees working.for me in 8. El Remodeling
any capacity.[No workers'gyp.insurance required.] 9. CI Demolition
3.0I am a homeowner doing all work myself[No workers'comp.insurance required.]t •
4.01 am a homeowner and will be hiring contractors to conduct all work on my property. 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.
12.0 Plumbing repairs or additions
5.0 I am a general contractor and I have hired the subcontractors listed on the attached sheet. 13.�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.['Other ,,, ,,
152,§1(4),and we have no employees.[No workers'comp.insurance required.] •
•
'Any applicant that checks box NI 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. •
tContraators that check this boor 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,theyy must provide their workers'comp.policy number.. .
Iam an employer that Lc providing workers'compensation insurance for my employees. Below is the policy andjob site
information. A.A-4•Aruv-s.
Insurance Company Name: I �.ei;IX/ Ste,
• •
Policy#or Self ins.Lic.#: Va C D.3 93 9, Expiration Date: la is- , .1
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 • and peugifief of perjury that the informgtion provided above is true and correct
,Signature: • Date:
to • {v,
-Official use only. Do not write in this area,to be completed by city or town offidal
• Citpphr 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#:
"Z. F *z°A;743e5aele,ede
Office of Consumer Affairs and Business Regulation
1000 Washington Street-Suite 710
Boston, :,,,..-:,, ., usetts 02118
Home Improve : .. • :ctor Registration
. . ..,...._,.._,..._ ,.
-,,-.,: .•,:21,7,-,,:-.••••:.,•.-.:4-.11:9 ., Type: Individual P.O.BOX 52 Expiration: 06/15/2021
WEST DENNIS,MA 02670 p ,-, - •;-2:: •:-.-
\ -,... ."-.,_ .:.-.• ,... t-: - '
am.mme ...emamomm,,,e.m.•• •••.••••••man••••update Address and Rotten Card.
SCA 1 0 2ON105/17
.at rAerimo,ters4A1A4tVageaMaerre&setaXi :
Otani of Consumer Affairs a Business Regulation • ,
HOME IMPROVEigeff CONTRACTOR Registratbn valid for Individual use only
:•
BarggzincOvichall
before the expiration date. if found return to: 5..
MOWN] Office of Consumer Affairs and Business Regulation
06/16,2023 i 1000 Washington Street •Suite 710 ,
MICHAEL I.tjteiflii Boston,MA.021/1ir ,
•: .,:!./- / /.
•
. - .
MICHAEL F.MC -&-----: .5'
6 RANGLEY LN. V,-,,,-;.,-77...4:;-' /40,601(4.4•4' - li //
r
SOUTH DENNIS,tviAiktiar t,, ' Not val out signature
Undersecretary
"N, ,-
.11.. commonweafth of Mossechusetts
Division of Professional Licensers ,B:11.01 PERFORMANCE INSTITUTE,INC.
11,1 Board of BUilding R-.! ,i. , and Standards
107 Hermes Road,Suite 210
Con ,: ;!) -.). 4 - ..r Malta,NY 12020
-t. " (377)274-1274
CS-058633 ,O) . '''_ :-: -1 . Igpires:04t10/2020 www.bplorg
MICHAS.J • - Tilt;.'., s!i tft 4
PO BOX_ .4,62 iil '''' .!1 40i -,----, 5
WEST LIENNIV.MA: - • - . '
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bisiiiriov- +.•
..:I'.,:r : re,:ffr.•-ze-,,, .
Commissioner •-, e- K. Dttulai.
.--
" (SEE REVERSE SIDE FOR MIGRATIONS AND EXPIRATION OATES)
4- -
littaaei AfteaillY
-14)Box 52
West Dennis MA'62 670
(5208 ) 80 - 6 Cy
. . ,