HomeMy WebLinkAboutBLD-22-007157 ;Office Use se Only
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EXPRESS BUILDING PERMIT APPLICAT
TOWN OF YARMOUTH RECEIVED
Yarmouth Building Department
1146 Route 28 JUN 10 2022
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261 BUll v
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By. -
CONSTRUCTION ADDRESS: 1 Z.,, Sit,Cit
ASSESSOR'S INFORMATION:
Map: Parcel:
OWNER: rif4 V1 k til 6.(S14A6 t in 1 2— et_ S .7--'. S'— 3 V h 7
NAME PRESENT ADD SS TEL. #
CONTRACTOR: 6rK I. ( 7 n ,.,- 11.tit 1 vi 4iJ&. , 4-024 v y (-5-- ) g'2.6 —2,5-4y
NAME MAILING ADDRESS f TEL.#
Residential ❑Commercial Est.Cost of Construction$ �'7.SDv, z-v
b-i r ti e
Home Improvement Contractor Lic.# ( 1 f LSL I' Construction Supervisor Lic.# es" t l;Z SLq
Workman's Compensation Insurance: (check one)
❑ I am the homeowner 10 I am the sole proprietor 0 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 Replacement windows: # Replacement doors: #
Roofing: #of Squares I t ()(34 )Remove existing* (max.2 layers) Insulation
Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing
*The debris will be disposed of at: 5 (_.--(W at in H t.j
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 license and for prosecution under M.G.L.Ch.268,Section I.
Applicant's Signature: Date: (o//L'/ -
Owners Signature(or attachment Yi„,_
Date: g //7/ Z
Approved By: Date: 6 - 10`
Building Official(or designee) EMAIL ADDRESS:
Zoning District:
Historical District: ❑ Yes ❑ No Flood Plain Zone: 0 Yes 0 No
Water Resource Protection District: Within 100 ft.of Wetlands:
0 Yes 0 No 0 Yes ❑ No
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_ _ The Commonwealth of Massachusetts
11:)=,►W -iri Department of Industrial Accidents
=41i1== 1 Congress Street, Suite 100
_ `_ Boston, MA 02114-2017
_ _ www.mass.gov/dia
\Y orkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): 645/ /
Address: 1 Pz _ 04
City/State/Zip: Zr-L- d.cA, /1 Poe # •, •-°e' r 2-L _ Z-< /
Are you an employer?Check the appropriate box: Type of project(required):
1.0 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. Remodeling
any capacity. [No workers'comp. insurance required.]
3. I am a homeowner doing all work myself. [No workers'comp.insurance required.]t
—
9. E Demolition
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.❑ Electrical repairs or additions
proprietors with no employees.
- 12.Q Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.El Roof repairs
These sub-contractprs have employees and have workers'comp. insurance.:
14.D Other
6.111 We are a corporation and its officers have exercised their right of exemption per MGL c.
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: Z /711 2,-''"2.---e
Phone#: (.?o) ze c, Z. Se )
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 Massachusettse
Division o Occupational Licensur
Board of Building Re ulations and Standards
C o nsti clf rnisor
CS-082529 pines: 12/10/2023
BASIL J CONRO' };*! 1 '
7 DANA ROAD
FORESTDAL;M qy
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464 lJ
Commissioner � �• �vnc�Lca
THE COMMONWEALTH OF MASSACHUSETTS
•
Office of Consumer Affa:;s&Business Regulation
HOMEIMPROV:„ CONTRACTOR
Re•' ,;
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BASIL CONGRO
D/B/A CONGRO RE *
BASIL J.CONGRO
7 DANA RD.
FORESTDALE, MA 026414.
Undersecretary
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