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Home My WebLink AboutBLD-23-003545 2/Z/Verl,, Office Use Only O�.YA�`r �. • �\ Permit# 0 `. Amount [ ` MXtt H [XK 4' ,�, „ ,g? Permit expires 180 days from issue date 13W-23--(1)35 - EXPRESS BUILDING PERMIT APPLICATION _.._ .. .�.. TOWN OF YARMOUTH RECEIVED Yarmouth Building Department 1146 Route 28 DEC 2 9 2022 South Yarmouth,MA 02664 (508) 398-2231 Ext. 1261 BUILDING DEPARTMENT ay - CONSTRUCTION ADDRESS: 635 W Yarmouth Road, West Yarmouth, MA 02673 ASSESSOR'S INFORMATION: Map: 85 Parcel: 10 OWNER: Town of Yarmo 1146 Route 28 508-398-2231 NAME PRESENT ADDRESS TEL. # CONTRACTOR: Delphi Constru 17 Cape Drive, Mashpee, ; 508-893-9900 `5b5.---12.1--tv(O NAME MAILING ADDRESS TEL.# ❑Residential Cl Commercial Est.Cost of Construction$310'000 Lic.#CS-112067 Construction Home Improvement Contractor Lie.# Supervisor Workman's Compensation Insurance: (check one) 0 1 am the homeowner 0 I am the sole proprietor 0 I have Worker's Compensation Insurance Alliant Insurance Services, Inc. Insurance Company Name: Worker'sCom Polic 54309736 _-- __-- p WORK TO BE PERFORMED Tent El Duration (Fire Retardant Certificate attached?) Wood Stove El Siding: #of Squares 25 Replacement windows:# Replacement doors: #5 Roofing: #of Squares (❑)Remove existing*(max.2 layers) Insulation__ I 1 Old Kings Highway/Historic Dist. (D)Replacing like for like Pool fencing *The debris will be disposed of at: 569 Winthrop Street, Taunton, MA 02780 _. Location of Facility I declare under penalties of perjury that the statements herein contained are true and correct to the best of my knowledge and belief. I understand that any false answer(s) will be just cause for denial or revocation of my license and for prosecution under M.G.L.Ch.268,Section 1. N=gn��Ma, �P ansru� n.„....�on c ...M 12/29/2022 r 4 Uas ra. n�aa N�o� Applicant's Signature: Michael Paronich �,,:s�o Date: Owners Signature(or attachment) Date: Approved By: Date: /� A, -22- Building 0 esi ee) EMAIL 'SS: Zoning District: Historical District: Yes No Flood Ptain Zone: 2 Yes I No Water Resource Protection District: Within 100 ft.of Wetlands: Yes Li No L Yes ,. No Commonwealth of Ma:,sachusetts Division of Occupational Licensure Board of Building Re ulations and Standards Co nst Bonn T$ r visor v .p CS-112067 �ti. E spires: 10/10/2023 MICHAEL I P*RON -. 39 BLUE HERON D PLYMOUTH fib• � ��.� �` � u � , -`z Commissioner i°, Fil&naca.. • • The Commonwealth of Massachusetts ?r 1= 1!t , Department of Industrial Accidents _;,j1= 1 Congress Street,Suite 100 __�'• i Boston,MA 02114-2017 wwwmass.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): Delphi Construction, Inc. Address:255 Bear Hill Road City/State/Zip:Waltham, MA 02451 Phone#:508-815-5555 Are you an employer?Check the appropriate box: Type of project(required): LID Q✓ I am a employer with 50 employees(full and/or part-time).* 7. ❑New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. Q Remodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. El Demolition 10❑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 11.0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.aR0of repairs These sub-contractors have employees and have workers'comp.insurance.# 6.❑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#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. tContractors 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:Alliant Insurance Services, Inc. Policy#or Self-ins.Lie.#:54309736 Expiration Date:7/1/23 Job Site Address:635 W Yarmouth Road City/State/Zip:W Yarmouth, MA 0267 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 c fy unde the '' s and alties of perjury that the information provided above is true and correct. Signature: Date: I421/ZZ Phone#:5 8-815-5555 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#: