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Home My WebLink AboutBLD-23-001898 o � O /6l)? z/ Z. Permit KALL/q � Fee S Jc d,O ; Permit expires 6 months from MATTA 1't CS S� ,,,,,,« 'issue date. c ✓ t3 LO —2 3 -bd i EXPRESS BUILDING PERMIT APPLICAT. • TOWN OF YARMOUTH RECEIVED Yarmouth Building Department 1146 Route 28 OCT 112022 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 BUILDING DEPARTMENT By CONSTRUCTION ADDRESS: /2 120,),- -.GPAM i M ytru.M,Ad, OoU/I ---_ ASSESSOR'S INFORMATION: Map: Parcel: / OWNER: CX0 - X�� />Z v2,G�2�5ek c {M' ,440el -- 5 0 , I"k7—9v2`/—4'7 NAME PRESENT ADDRESS TEL 4.S3 TEL. # n, CONTRACTOR: f�� /e„ .� ,iiiviet, 4/ /l pp // N MAILING ADDRESS e2-1L ley' TEL Uit L,.# esidential ❑Commercial ❑Est.Cost of Construction$ // .5-691,-00 Home Improvement Contractor Lic.# /of 1t5f Construction Supervisor Lie.# Pr> 3q Workman's Compensation Insuranceeck one) ❑ I am the homeowner VI am the sole proprietor ❑ I have Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy# WORK TO BE PERFORMED ❑Tent (Fire Retardant Certificate attached) ❑Wood Stove Shed ❑Siding: #of Squares ❑Replacement windows:# ❑Replacement doors: # ❑ Re-roof: #of Squares /0� ❑Insulation tripping old shingles* ()going over layers of existing roof ❑ Old Kings Highway/Historic District �.y� JJ Roofing/Siding(Like for Like) *The debris will be disposed of at: '�J l j c lr , ,GG�j �4, d�� G 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 'cense and for prosecution under M.G.L.Ch.268,Section 1. v Applicant's Signature: ,J4Date: /0 /1 — e2,1 Owners Signature(or attachment) ---) Date: /0 "`/0 — Approved By: , `" - -j / Date: AO -'—/� u '2:2— Building O ( esignee) �/ Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: ❑ Yes ❑ No ❑ Yes ❑• No 3/01 1 _ • The Commonwealth of Massachusetts Department of Industrial Accidents 111_ Office of Investigations __ _ 600 Washington Street �1�'= Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): J`Y 1 t-'ft /t' /41 Address: /C /1,c �2 City/State/Zip: -2& : ( 2 G/ i Phone #: _ y� )-1 * 61Z/ Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. El I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.1.2 I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have 8. Demolition working for me in any capacity. employees and have workers' 9. Building addition [No workers' comp. insurance comp. insurance. required.] 5. Ei We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions m self. [No workers' comp. right of exemption per MGL yp 12.0 Roof repairs insurance required.]t c. 152, §1(4),and we have no 13.❑Other 3a.❑ I am a homeowner acting as a employees. [No workers' general contractor(refer to#4) comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensatiorltoolicy 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 Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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 S250.00 a day against the violator. Be advised that 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 i Siggatic; � Date: 7( // -- Phone# 5 73 - 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 It: Commonwealth of Massachusetts 1111) Division of Professional Licensure Board of Building Regulations and Standards ConstFtt>i+t}nH Spptvisor CS-104459 1pires:09/02/2023 STEPHEN P PAZZtHt 10 MARK LAME HARWICH MA 62645 • Commissioner G K. l 411.1ta, Office of Consumer Affairs and Business Regulabon 1000 Washn2ion Sweet-Suite 710 Basilan.Massachusetts 02118 tierce enprol meM Cx3Actor ReglstrMeon STPNET.P tigt:_a1 As;a:d3Fe:a laliJi !;••8 i ba tKE.'4P MALIFA NCME ALMOVE1EN?S EW(Y.�M1 4':i']�.+p. te MAW LANE NAPAPCN lit xcis tle4.r AtlFr OMe.CAW • re:czlrrvAArra i leaborz lembdors weer Neaelr.hlaar rrNReaeTna 1 yaks farlairyedrei use slr Me 1.4.44 aphis% I Mood rcekev 1� alm.e.il.. beeair 0Om Ostsemat*Ma w IWaBea Meg.,ere 141134 m. lioneirinshisArm-l.erno s:ErPE}s PANZELA isalm.w atilt titsa 5'Z ireNP 1Etutfi«OW 4P:kgttl!*tts )11‘ s:aiott M+ctZrit M tait .iterctl VA Imes valid without iarriir<ure It r0105at Page# --_of --__.pages Stephen P. Mazzur 10 Mark Lane Harwich, MA 02645 (508)737-9212 PROPOSAL SUBMITTED TO: JOB NAME ADDRESS Cr - r Pr # t JOB LOCATION DATES � PHONE# Of_ ii ' . aZ `Ol(' �a DATE OF PLANS ftrIt -4 f1 36 r Q 11 . Olffill It %=a hereby submit specifications and estimates for: r �_ J - f li.ber tialc(r4e eri6re .s Li-7-4;9 c a cezrea, A.44 Aze s__ cam ,�i/ / �? Pam � F'"iiLQ-J { --_ , ‹ Ur-x'lGGZ!'Jf /1Q1 !� — _ 1 .. . ( e:r • rocl, ' r1 a e1L1sC nfandcum des r_ tC.LI __y.t.. eincr7t ....... ...... ... 410..i_rials,_ _arc_zrried.__._hy _f_n _egiue--faatarer we2rx_maeask;o egaraniced r�.-.-tom .1e/ %e propose hereby to furnish material and labor—complete in accordance with the above specifications • r7 O0 $ �i o ( p Ions for the sum of: /� ��. with payments to be made as follows: ga-. r • Dollars inv y, t � Any all lion or deviation fromCr bnve6 k 'too, \ / will be executed only upon written order, will'be .nv� ing extra Respectfully - over and above the estimate. All agr••ment on n (Hon strikes, submitted accidents,or delays beyond our co/r„ ! 0 l Note—this proposal may be withdrawn by us if not accepted within — le " I O!A' �, !. r days. l Zicceptortce of Vropolaf The above prices,specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payments will be made as outlined above./V l/ Signature r Date of Acceptance g d r2 Signature A-NC3819/T-3850 09-11