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Home My WebLink AboutBLD-23-000974 /o dZ(7ZZ ..,0i'.Y Office Use Only C Permit#C tt .0 _ yi a disk/ Amount/Q�,fid ''"jArMTTA n s t,ft,�t,d` d.�' Permit expires 180 days from � P Y '! ' . issue date ,5U -23-O(Og1 EXPRESS BUILDING PERMIT APPLICATIO E C E 8 V E D TOWN OF YARMOUTH Yarmouth Building Department 1 1146 Route 28 AUG 23 2022 South Yarmouth, MA 02664 ___ i (508) 398-2231 Ext. 1261 BUILDING DEPARTMENT /� '�` By: CONSTRUCTION ADDRESS: (3I® //)- I� 1 ASSESSOR'S INFORMATION: Map: Parcel: OWNER: ) . I J & i s, NAMEN PRESENT ADDRESS TEL. # Mitt`�'l.r J ot, i .2qt[ L ' ,'/,5" / . NAME ki__4 MAILING ADDRESS TEL.# ❑Residential commercial Est.Cost of Construction$ a.27d Home Improvement Contractor Lic.# /35 8'g P Construction Supervisor Lie.# dg'//341 Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor ' 15j I have Worker's Compensation Insurance Insurance Company Name: 4Lfr7 44,7 Worker's Comp.Policy#4'e� yen 2/3 / .e4 WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove I I Siding: #of Squares Replacement windows:# Replacement doors: # / 0ZO44t Roofing: #of Squares (El)Remove existing*(max.2 layers) Insulation Old Kings Highway/Historic Dist. (n)Replacing like for like Pool fencing *The debris will be disposed of at: ��,',,,,,.. ✓`. --m,,,,,,,ii.,t_ 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 rev a' f my license and for prosecution under M.G.L.Ch.268,Section I. Applicant's Signature: Date: '23 . Z.— Owners Signature(or attachment Date: V -.02113 Approved By: Date: /r 7 Building Official(or designee) L ADDRESS: Zoning District: Historical District: Yes No Flood Plain Zone: 1 Yes No Water Resource Protection District: Within 100 ft.of Wetlands: = Yes No '2 Yes 7 No THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs.&Business Regulation Registration valid for individual use only before the HOME IMPROVEMENT CONTRACTOR expiration date. If found return to: TYPE LLC Office of Consumer Affairs and Business Regulation Registration Expiration 1000 Washington Street -Suite 710 13--88-7 08/14/2024 Boston, MA 02118 A J NARDONE CARPENTRY LLC. AICHAEL J. NARDONE-, / '.99 WHITES PATH ,� >OUTH YARMOUTH, MA,05664 -:,. r /vr�dGG'� i� y"' Undersecretary & ��/((j. of valid without signature Commonwealth of Massachusetts t Division of Professional Licensure Board of Building Regulations and Standards Consry tt$Aisor, CS-081139 ,' Ntepires:09/16/2023 MICHAEL J NARDONE r 299 WHITES PATH % r,, SOUTH YARMOUTH MA 02664 ,,,,r p Commissioner eAAA K. i7�rrr ukcck.. ,tom` The Commonwealth of Massachusetts �_" Department�'i P of Industrial Accidents d y I Congress Street,Suite 100 Boston,MA 02114 2017 ON`Y' WWW.mass.aov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers, TO BE FILED WITH THE PERMITTING AUTHORITY. A Iicant Information Name (Business/Organization/Individual): �U I Please Print Le zbI YI • Address: a9 Vla-e j '-A-V • City/State/Zip: X (1III j '7 f' Phone #: -�/ f '02� Are you an employer? Check the appropriate box: l. I am a employer with Type of project (required): _ ` employees(full and/or part-time).* 2. I am a sole proprietor or partnership and have no employees working for me in 7. New construction $• remodelin any capacity,[No workers'comp.insurance required.) g 3.0 I am a homeowner doing all work myself [No workers'comp.insurance required.]t 9. [ Demolition �1.❑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 10 Building addition proprietors with no employees, 11.❑ Electrical repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet 17 Plumbing repairs or additions These sub-contractors have employees and have workers'comp. insurance.t 13.El Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption perMGL c, 152,§i(4),and we have no employees. 14•❑Other [No workers'comp,insurance required.] *Any applicant that checks box*I 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: G,• ,i--- Policy#or Self-ins.Lic.#: ive- /'O 703 V/7 -`"`�4 Expiration Date: 3^ a--23 Job Site Address: .,21 d j 4,4®y Attach a copy of the workers' compensation policy declaration page(showing theta e cip: eb if - e2ii�" y Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable1by a f e up to$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 under the p "" s and p fP penalties o perjury u that the information provided above is true and cSi attire: ilorrect. A illy%`/`g—ir Date: 57"a3v__ Phone#: — 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): I. Board of Health 2. Building Department 3.Cityfrown Clerk 4. Electrical Inspector S. Plumbing Inspector 6.Other Contact Person: Phone#: