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Home My WebLink AboutBLD-23-001859 C •4'.YRR4eo i+ iktiet j Office Use Only 1//1� ' Y+ ! 1 I Pennit# cam' 'I j 3 i/ . Ou. il.t� y iU1 I&7 .00 c MATTACII [SEJ� 'Amount Permit expires 180 days from I issue date EXPRESS BUILDING PERMIT APPLICATION)� � bb g5 9 TOWN OF YARMOUTH Yarmouth Building Department R F C E a V E 1 1146 Route 28 1 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 OCT 06 2022 211�J CONSTRUCTION ADDRESS: "'I BUILDING DEPARTMENT By: __ ASSESSOR'S INFORMATION: Map: Parcel: t. OWNER: Z/9-(9,fie /0 r e s ,et (5,') 6 fg. ! q NAME / PRESENT ADDRESSE / T L. # CONTRACTOR: NAME ''cam iL rl4r, ljid",V 6 /' . : p 2 k5 2r� AME SrD MAILING ADDRESS TEL.# ❑Residential ❑Commercial 2 L/DC/ C��. Est.Cost of Construction$ Home Improvement Contractor Lic.# /? .Mr Construction Supervisor Lic.# Oct,'"/0642 /y Workman's Compensation Insurance: eck one) ❑ I am the homeowner , I am the sole proprietor ❑ I have Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy# WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares A..... Replacement windows: # Replacement doors: # Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: Gotehe li a/7nI A tYt'14,, p Location of Facili I declare under penalties of perjury th is herein ained are t d correct to the best of my knowledge and belief. I understand that any false answer(s) will be just cause for denial or r c of my lice e an or prose under M.G.L.Ch.268,Section 1. Applicant's Signature: C / 6' Date: �_ Owners Signature(or attachment) 2..".......-- Date: Approved By: //c7 �j 7�Building Official esignDate: ��/ �"e EMAIL ADDRESS: Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes L No • The Commonwealth of Massachusetts isil!il Department of Industrial Accidents 1 Congress Street, Suite 100 ..I i ,t.' Boston, MA 02114-2017 `'M v._ www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information 71/ � Please Print Legibly "...,--Name (Business/Organization/Individual): ,-t"�-ll Address: 2 /i"4 - /2/' # City/State/Zip:__� -'/`�,�i2 C 'S (26?'/ Phone #: ç7'( 7 �/ �� Are you an employer?Check the appropriate box: Type of project(required): 1.[I am a e er with employees(full and/or part-time).* 2. am a sole proprietor or partnership and have no employees workingfor me in 7. — New construction any capacity. [No workers'comp. insurance required.] 8. — Remodeling 3.D I am a homeowner doing all work myself. [No workers'comp. insurance required.]t 9. -_ Demolition 4.[I am a homeowner and will be hiring contractors to conduct all work on my roe I will 10 n Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.[ Electrical repairs or additions proprietors with no employees. - 5.[I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 12.[Plumbing repairs or additions These sub-contractors have employees and have workers'comp. insurance.t 13•[Roof repairs 6.E 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. $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 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 ma :- far-warded to the Office of Investigations of the DIA for insurance coverage verific. �j�_ I do her-,y certi . 011er the pains an, 'enalties o :-rfury that the information provided above is true'and correct. Signature: - ,-/ — Date: / c2 2 Phone#: , 2 `f 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#: Michael Silva 82 Walton AV. Hyannis Mass. 02601 CSFA106219 Laurie Mace 225 Wester Rd. South Yarmouth 02664 Description of work. Remove white cedar shingles on left side of house Gable. Rear of house. Right side of house Gable. Install new tripod House wrap Install Malbec dipped one coat Shingles. Replace all window cap flashing. Repair rotten trim not included in price Remove all old shingles and debris from property. Total price, labor and material cost. $22,400.00 payments Half down To start.The rest when completed. Michael-Silva '� Laurie Mace p /'.� " C: ._—9,--= ,ram. (i.AA.-/ ' ek \, Y' • Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Constructio(,,$ W1140' & 2 Family CSFA-106219 s MICHAEL SIU/A Empires:06/28/2023 82 WALTON AVENUE m l ' J HYANNIS MA2601 4 it- Commissioner dtpa >ri � • ."/itgito- arisnnrau sire& ine 9 +on HOME IMPROVEM NT CONTRACTOR w • • TYPE:Individual Registration Expiration 175708 06/03/2023 MICHAEL SILVA MICHAEL D.SILVA (� • 82 WALTON AVE. HYANNNIS,MA 02601 Undersecretary •