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Home My WebLink AboutBLD-23-002705 ern //- I& -ZZ O1..y�R RECEIVED Office Use O/inly'] 5' �{O JV15 Permit#��17�/(X� y y O . H NO 2022 Amount V `�Teo_ 0aysfrom EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 1 C 6L)Cl l ' ,2t-,vvi ( t 9 r PO e S.-1---- X-1,rOf 0 t-i ASSESSOR'S INFORMATION: Map: '7 (.7 Parcel: l,..16i OWNER: /1'1(e ►1..0 ef f`�.l Il� 11 Ott ( vV1 ( /� (7 -n ( e' lCJ 3/ c o 3 l NAME // PRESENT ADDRESS 7 TEL. # ' / �/ (f CONTRACTOR: NAMEl,t Yt S' W(6 J it MAILING D�RE 170 .4�;Ic. l If�4 64_ Yr ' 7 7 ( �� ( /11 O TEL.# ❑Residential 0 Commercial Est.Cost of Construction$ 1;. O Q • t9 C ? . Home Improvement Contractor Lic.# (7 ?). Construction Supervisor Lic.# (CU Z.X 9 0 Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor /❑1 have Worker's Compensation Insurancelr lk/1 , IJet Ct0 Worker'sPolic V LUC—Ice 4,0 / ?CAS-- 2022A Insurance Company Name: �� . Comp. Y# 1 WORK TO BE PERFORMED Tent 0 Duration (Fire Retardant Certificate attached?) Wood Stove El Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares (❑)Remove existing* (max.2 layers) Insulation n nOld Kings Highway/Historic Dist. J Replacing like for like Pool fencing r *The debris will be disposed of at: /t"✓t✓{'L C v I 4 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 tion of y Ii nse 'for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: VI' /0VZZ Owners Signature(or attac ment) ', ;17 ,.....,r- D ,c Date: /Date: ///r1,r/'2" �. Approved By: /5---5."5_ Building Official(or ' ne EMAIL ADDRESS Zoning District: Historical District: Yes ,I No Flood Plain Zone: C Yes C No Water Resource Protection District: Within 100 ft.of Wetlands: .1 Yes 1: No L i Yes No The Commonwealth of Massachusetts a I— 1, Department of Industrial Accidents l 1 Congress Street, Suite 100 _ � 1 Boston,MA 02114-2017 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): John J. Sambogna LLC Address: PO Box 1751 City/State/Zip: Harwich, MA 02645 _ Phone #: 774-994-1880 Are you an employer?Check the appropriate box: Type of project(required): If]I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.®I am a sole proprietor or partnership and have no employees working for me in 8. E Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑ Demolition 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 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.❑Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors 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. 14.0 Other Replace 1 door 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. I.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: A.I.M. Mutual Insurance Company Policy#or Self-ins.Lic.#: VWC-100-6017025-2022A Expiration Date:01/24/2023 Job Site Address: 19 Waltham Cir city/state/zip: West Yarmouth, MA 02673 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 under the pains and penalties of perjury that the information provided above is true and correct. Signature: /'-Z/, , Date: 10/14/2021 Phone#: 774-994-1880 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#: Commonwealth of Massachusetts iDivision of Occupational Licensure -f,0. Board of Building Re{,`fulations and Standards Constktit * e/rvisor it ', 'p CS-102290 ' Tres: 11124/2024 JOHN J SAt3 `e £ n 'Ii i r r++i P O BOX 74Ot :44 i - I YARMOUTHR 1. i 11 THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs.4& Business Regulation HOME IMPROVE a T CONTRACTOR Recjst ,,l4. 4 t' :trtion y I4 JOHN J SAMBOGNA, 1 t .. ' -. . ';.. '��. JOHN SAMBOGNA 3 MAIN ST , UNIT 19 EASTHAM, MA 02642 w�a .:�� undersecretarys r