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Home My WebLink AboutBLD-23-000795 ir Yq RECEIVED Office Use Only I _: cA15 2022 Perniit#+i, Amount cs)an�"'°•"' c B U I a '�L L- Permit expires 180 days from By:_ A issue date SLD-23 4)057ci.S— EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 (508)398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 50 . _re vl Ce/Y) SIUZAC- ASSESSOR'S INFORMATION: r>4 y, 1.(it Map: Parcel: �t / OWNER: 1 �� 1 l-J>7t OH ✓rt s tl-el .7 O Fei Ste'- s-1. 754 5.77/�,7 NAME PRESENT ADDRESS TEL # CONTRACTOR:£3 1/T L4/1�i-% 7 /)G flat' / / D2 L-f` �MrL-G"L SC/ NAME U MAILING ADDRESS / TEL.# `F(Residential a Commercial Est.Cost of Construction$ 3 16 Home Improvement Contractor Lie.# f`-i 4 R p Construction Supervisor Lie.# d k 25 2 -q Workman's Compensation Insurance: (check one) I am the homeowner FOG am the sole proprietor 1 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 12- 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: i;Ou r V1_L. '`P 1 / Location of Facility 1 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.Applicant's Signature: Q Date: CJ iici '2 2- Owners Signature(or attachme t ��-'' O Date: ' / /lll J/Z/�� Approved By: Date: g--/ V �v Building Of6cc(or des ee) A ADDRESS: Zoning District: Historical District: Yes No Flood Plain Zone: Yes No Water Resource Protection District: Within 100 ft.of Wetlands: i' Yes 1 No Yes No r�\ The Commonwealth of Massachusetts 1E1101• 111' 1= Department of Industrial Accidents 7 =Lem 1 Congress Street, Suite 100 Boston, MA 02114-2017 • _ www.mass.gov/dia \j orkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): 6,41-6I / Address: I (7%• 1 , d City/State/Zip:i�2 J 1,4 Imo- Ley Phone #: ($ ) 2-54 / Are you an employer?Check the appropriate box: Type of project(required): l._ I am a employer with employees(full and/or part-time).* 7. ❑New construction I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers'comp.insurance required.] 8. ® Remodeling 3. I am a homeowner doing all work myself. [No workers'comp. insurance required.]t 9. Demolition 4.[II am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sol 11.�] Electrical repairs or additions proprietors with no employees. 5.❑ m I a 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.Q Roof repairs 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. $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 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: Date: g Phone#: —�S 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 Aria Division of Occupational Licensure Board of Building R,eeulations and Standards Constli&t&b [vvisor CS-082529 * 12/10/2023 BASIL J CONpRO ,, 7 DANA ROAD FORESTDAL'E'�MA 02644 3`� () IMAN) Commissioner (1.0• K. Y . THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Individual Registration Expiration 141496 05/15/2024 BASIL CONGRO D/B/A CONGRO REMODELIN G I '77 '72-.2A3 w ! BASIL J.CONGRO fr iI 7 DANA RD. `?,_ _ ", GG. %ali.Gc' FORESTDALE, MA 02644 , _%° Undersecretary