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Home My WebLink AboutBLD-23-002645 ' , ppaI1- /`�" Office Use OOnlyk= \ P«mit# ev 53 O - +.;. H' ,Amount -AA ,4„�-'., 4' ° • . Permit expires 180 days from issue date - 6 r%-D -.2 3 -D0 a_ii, N5 EXPRESS BUILDING PERMIT APPLICATIcdt C E I V E D TOWN OF YARMOUTH Yarmouth Building Department NOV 14 2022 1146 Route 28 South Y Yarmouth, MA 02664 B U I LefOz N-r 508 398-2231 Ext, 1261 BY: ll.�� CONSTRUCTION ADDRESS: 15 West rd ASSESSOR'S INFORMATION: Map: 22 Parcel: 35 OWNER: jack matiasevich 32812 mermaid cir 808-298-8839 NAME - PRESENT ADDRESS TEL. # CONTRACTOR: ralph crossen 3 herring run rd 5089223195 NAME MAILING ADDRESS TEI.. la Residential 0 Commercial Est.Cost of Construction$4000 Home Improvement Contractor Lie.# 11367 7 3 U/ 9 7? Construction Supervisor Lie.#070029 Workman's Compensation Insurance: (check one) 0 I am the homeowner O. I am the sole proprietor 0 I have Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy# WORK TO BE PERFORMED Tent 1:11Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares 14 Replacement windows:# Replacement doors: # Roofing: #of Squares (fl)Remove existing* (max.2 layers) Insulation I I ri Old Kings Highway/Historic Dist. (EI)Replacing like for like Pool fencing cavossa, Falmouth r The debris will be disposed of at: Lo :':a of Facility I declare under penalties of perjury that the s--s.o'' is herein tamed: true and correct to the best of my knowledge and belief. I understand that any false answers) grill be just cause for denial orrevocat;•• +,y lrpros • ion •der M.G.L.Ch.268,Section I. l / 11-13-22 Applicant's Signature: ( / Date: irli Owners Signature(or a4achment) �_ e, /,..% Date: 11-13-22 -i0 �' ///- �1 Approved By: Date: Building Offici r d . ne EMAIL • 4:4 RESS: Zoning District: Historical District: . Yes No Flood Plain Zone: - Yes -: No Water Resource Protection District: Within 100 ft.of Wetlands: L. Yes - No . Yes _s No The Commonwealth of Massachusetts Department of Industrial Accidents =`•` Mir1 Congress Street, Suite 100 Boston, MA 02114-2017 r.�' 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): ralph crosses Address: 3 herring run rd City/State/Zip:east sandwich Phone#: 508-922-3195 Are you an employer?Check the appropriate box: Type of project(required): I.01 am a employer with employees(full and/or part-time).* 7. []New construction 2.1-11 am a sole proprietor or partnership and have no employees working for me in j 8. ®Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.Q I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 Q Building addition 4.❑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.QElectrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.01 am a general contractor and 1 have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contactors have employees and have workers'comp,insurance.t 14.EOther siding 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c, 152,§1(4),and we have no employees.[No workers'camp.insurance required.] l *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. I-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: 15 west rd City/State/Zip: Yarmouth 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,,,, r ai 5 tes perjury that the information provided above is true and correct Signature: _ Date: 11-13-22 Phone : 508-922-3195 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.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other - Contact Person: Phone#: Commonwealth of Massachusetts II Board of Occupational Licensure • Board of Building Re ulations and Standards Const{ lr rrvisor CS-070029 zy ires: 11/15/2024 RALPH M CIFIAOS `' 5 3 HERRING OWN Q EAST SANDYC �OI.Ldd1� Commissioner THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Aftat*,&Business Regulation HOME IMPROVE ENTCONTRACTOR TYPE t vtduaI : -EXoiration 13Eb 24 RALPH CROSSEN e x D/B/A RALPH CROS N - "z RALPH M.CROSSEN ? *� ' 18 WOODRIDGE RD E.SANDWICH,MA 02537 f . Undersecretary • 1114