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Home My WebLink AboutBLD-23-003610 CCU,Q-1 - Office Use Only /�LPennit# L ' a'' ' 4 R 41 C' 9 0.OO 0 . " H Amount ';N MATTA E . I M '..Permit expires 180 days from ; issue date OLD _23 --00340 ICE EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department RECEIVED 1146 Route 28 South Yarmouth, MA 02664 JAN 03 293 (508) 398-2231 Ext. 1261 22 Wites Path BUILDING DEPARTMENT CONSTRUCTION ADDRESS: By ASSESSOR'S INFORMATION: Map: t 7 Parcel: f OWNER: 22 Whites Path LAG NAME PRESENT ADDRESS TEL. # CONTRACTOR: M J Naardone 299 Whites Path 508-631-6584 NAME MAILING ADDRESS TEL.# ❑Residential l7 Commercial Est.Cost of Construction S 8,000.00 Home Improvement Contractor Lic.#1 35887 Construction Supervisor Lic.#0811 39 Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor 0 I have Worker's Compensation Insurance Insurance Company Name: AIM Mutual Worker's Comp.Policy#AWC-400-7034172-2022A WORK TO BE PERFORMED Tent El Duration (Fire Retardant Certificate attached?) Wood Stove I I Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares 1 2 (n)Remove existing*(max.2 layers) Insulation I I Old Kings Highway/Historic Dist. Replacing like for like Pool fencing ._ *The debris will be disposed of at: Yarmouth Transfer 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 is nse and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: C " Date: 1-3-23 Owners Signature(or attachment) Date: 1-3-23 Approved By: Date: Building Offici or ee) EMAIL AD SS: Zoning District: Historical District: Yes ' No Flood Plain Zone: Yes No Water Resource Protection District: Within 100 ft.of Wetlands: r Yes No E Yes No The Commonwealth of Massachusetts ri31/9mi Department of Industrial Accidents fir I Congress Street,Suite 100 a= r Boston,MA 02114-2017 „��•° wwx.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):/ A , A f-P-am Address: c - 9 4jA tr, City/State/Zip: S. /4ivytf 14,7/- 0240 Phone#: -77/ eK,227 Are you an employer? Check the appropriate box: Type of project(required): i. I am a employer with J 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. �Ibdeling any capacity.[No workers'comp.insurance required.) 3. I am a homeowner doingall work myself t 9. C Demolition C y [No workers'comp.insurance required.] 4.D am a homeowner and will be hiring contractors to conduct all work on my p roPen3'• I will 10 ❑Building addition ensure that all contractors either have workers'compensation insurance or are sole ILO Electrical repairs or additions proprietors with no employees, 12.❑Plumbing repairs or additions 50 I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13. Roof airs These sub-contractors have employees and have workers'comp. insurance.; ❑ repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL e. 14.El Other • 152,3I(4),and we have no employees.[No workers'comp.insurance required,] *Any appl icant 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 roust 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. lithe sub-contractors have employees,they must provide their workers'comp.policy number. T am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. incurance Company Name: 4,771r 4 ii— Policy#or Self-ins.Lic.#: 13'4r/t /44'-703 (20.- 4 Expiration Date: 3- a-'23 Job Site Address: I 4/.k ) V City/State/Zip: , ' ;y, n'd DZs7 Attach a copy of the workers' compensation policy declaration page(showing the policy nber 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 p '' s and penalties of perjury that the information provided above is true and correct. /�•�'i Signature: M Date: Date: Phone#: U Ve' 72/ 9 9o9 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): 1.Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs.&Business Regulation Registration valid for individual use only before the HOME 1MPROVEMENT-:CONTRACTOR expiration date. If found return to: TYRE:LLC_- Office of Consumer Affairs and Business Regulation Registration ' E-zpiration 1000 Washington Street -Suite 710 135,887 08Jt412024 Boston,MA 02118 J J NARDONE CARPENTRY•LLC '1 i� ti i_i ar AICHAEL J.NARDONE`' 7 P ';1.1 0/ 1 4/44....„6/7"L„,..,..... '.99 WHITES PATHS ra��yam' ;OUTH YARMOUTH, MA'02564 Undersecretary i of valid without signature Commonwealth of Massachusetts IPDivision of Professional Licensure Board of Building Regulations�[ and Standards Constar f 16 ipsirvisor j i CS-081139 j'' � ijc�pires:09116/2023 MICHAEL J NARDONE Pp ,: y 299 WHITES PATH a p SOUTH YARMOUTH MA 02664 .r I Commissioner (lain, K. bY.v.ncito—