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Home My WebLink AboutBLD-23-001942 i'0•YRR`tr Office Use Onlyn h C �� Permit# MATTAcn E .-...3 .{Amount �,�� ` Permit expires 180 days from 1 issue date 8LD -23 -00042_ EXPRESS BUILDING PERMIT APPLICATI 0 E C E 9 V D TOWN OF YARMOUTH Yarmouth Building Department OCT 12 2022 1146Route28 South Yarmouth, MA 02664 BUILDING DEPARTMENT 9/...„4:, (508) 398-2231 Ext. 1261 / ,CONSTRUCTION ADDRESS: ? 3 �/ Ui. , C ,... ,---, ASSESSOR'S INFORMATION: Map: q Parcel: OWNER: y a ''I Cozi,G` J a G,t_ _S -^ ` •-$ 71/0, NAME RESENT ADDRESS TEL. # i CONTRACTOR: S —S-0 2 r. z eo-- 78 tt NAME MAILING ADDRESS TEL.# / esidential ❑Commercial Est. Cost of Construction$ '7 41�j Q,GO Home Improvement Contractor Lic.# n- 2-t `a-6• Construction Supervisor Lic.# LA/C— .3/ "'-' , ra W. Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor �I have Worker's Compensation Insurance h Insurance Company Name: & 10 tat Worker's Comp.Policy# l/C 3 0 5 WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove 0Siding. #of Squares Replacement windows: # Replacement doors: # oofing: #of Squares 76 ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: r a nt 5 , 1 p 4 Location of Facility I declare under penalties of perjury that the t ements herein cont -. 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 ion o y license and for• . cution under M.G.L.Ch.268,Section 1. qry �� Applicant's Signature: 0/L /41CJ Date: � 2. Owners Signature(or attach / Date: Approved By: ��✓" Date: / Building Official(o gne , ( EMAIL ADDRESS: Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes 0 No Water Resource Protection District: Within 100 ft. of Wetlands: 0 Yes 0 No 0 Yes ❑ No • The Commonwealth of Massachusetts . Z ,„is r Department of Industrial Accidents 1110 1 1 Congress Street, Suite 100 'l i Boston, MA 02114-2017 0„ _../ www.mass.gov/dia Workers'em Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information / Please Print Legibly Name (Business/Organization/Individual): ,'c+"C.7t . s f„ C ,,,C Address: 6,#"'1 � -C_v"1. Ce_. City/State/Zip: r.¢ Xo _ �'' /( S Phone #: o ? `f Are you employer?Check the appropriate box: Type of project(required): I. I am a employer with 2mployees(full and/or part-time).* 7. _ New construction 2.E1 I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity. [No workers'comp.insurance required.] — 9. ❑ Demolition ` 3.❑I am a homeowner doing all work myself.[No workers'comp. insurance required.]t 10 Building addition 4.0 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.❑ 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.El Roof 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. 14.7 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. 1.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. i� Insurance Company Name: t/�% �s isr'setit'9"4-/ /A- 5 i. Policy#or Self-ins.Lic. #: V'6—,�= 3/5'—6/ .K- '0/L Expiration Date: 27///' —O 3 Job Site Address: >3 4 Ley /' City/State/Zip: L 12J<�, (,: -t j Attach a copy of the workei�compenon 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 certi unde the ains andpe lties of perjury that the information provided above is true and correct. Signature: Date: /0/�z 2 Phone#: 5— 2 'q -/- i7 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#: 1 Commonwealth of Massachusetts IDivision of Professional Licensure Board of Building Re ulations and Standards Const U t A rvisor CS-111305 P r�pires:06/01/2023 ANDRE YARMALOVICHf 204 CINDEREJLO TERRACE MARSTONS LS MA 02648 4 lob. Air)/ss.1.1( Commissioner ,claia fi. bjFinc THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:'Individual Registration Ess&atign 172476 07/01/2024 ANDREI YARMALOUICH D/B/A BEL ISLANDS HOME IMPROVEMENT ANDREI YARMALOVICH � i) 204 CINDERELLA TER. ou''"'` "L' MARSTONS MILLS,MA 02648 Undersecretary /i‘r 411Frft\ Estimate Date Estimate it BEL ISLANDS Home Improvement 10I2T2022 2139 Bel Islands Home Improvement 204 Cinderella Ten ace Name I Address Marstons Mills, Ma,02648 Diane Coulopaulos 33 Appleby road, Belisiandsroofingandsiding.com West Yarmouth,ma 508-280-1794 508-364-6909 f Terms Project E It �:* i E Permit 250.00 250.00 Dumspter 450.00 450.00 _ /07/0-0 2--Z____ Total $7,450.00 Page 3