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Home My WebLink AboutBLDX-25-496 application i /Og yA�4 Office Use Only f-' \ �/y Permits* ll" �hlJ AmAmount9v \C°APO R„I EO\s, __-- a 31c-.325-Kq& EXPRESS BUILDING PERMIT APPLICAT e ' C E I V E D TOWN OF YARMOUTH Yarmouth Building Department 1 146 Route 28 APR 212025 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 BUI 7-Pa,.- i CONSTRUCTION ADDRESS: OWNER: �LCi /4441 4 9 f J 7_" E 1/47 $ C - Cr). C1 PC) \\\II 'RI.SI \1 \I)I)RESS 1I I CONTRACTOR: 4/i r c' 99 l?ice .5-'e) s- 5— 71l V,3 SC) N\\IF ,/ MAILING ADDRFSS TI I EMAIL: ?/"11-4 p t9,i. �O/� N J Residential mmercial Est.Cost of Construction S J S 0 CD Homeowner is Applicant? Yes No G r Home Improvement Contractor Lic.# /V S !o Construction Supervisor Lic.# CS— 0 17'S 3 C/ WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate required) Wood Stove sip Siding: #of Squares.�a?o Replacement windows: # Replacement doors: # Roofing: #of Squares Insulation Temporary Mobile Home Temporary Construction Trailer Demolition- Interior only Demolition Raze Structure Solar System ESS System Chimney Fence *Please submit utilit\ disconnect letters for electric & gas structures os er 75 scars old require historical res less r/--- e-r4 *The debris will be disposed of at 30V/ZeIGIAI 5p,, 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 answers) will be just cause for denial or revocation of m lic nd foe,„ro n nder M.G.L.Ch.268.Section 1. Applicant'.Signature ,-..----- / �� Date: - Owners Signature(or attachment) C��/ 'G � Date: L�" 09.7'Oaio'f : pp\ ros ed By Date Building Official(or designee) Res 6 24 0w 'I tC The Commonwealth of Massachusetts "' . Department of Industrial Accidents MaLJ Office of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information �,r� Please Print Legibly Name (Business/Organization/Individual): �_� " c>vt-- r Address: 9 7ti 0 City/State/Zip: '�,45-55 (iC"e"-� Phone #: S'�� S'W s'f`� Are you an employer? Check the appropriate box: Type of project(required): 1.0 I am a employer with 4. ❑ I am a general contractor and I — yees (full and/or part-time). * have hired the sub-contractors 6. ❑ New construction 2 I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition workingfor me in anycapacity. employees and have workers' P ty. t 9. ❑ Building addition [No workers' comp. insurance comp. insurance. required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions officers have theirrepairs or additions 3.El am a homeowner doing all work exercised 11. Plumbing eP myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, §1(4),and we have no 13�J e4r employees. [No workers' Other comp. insurance required.] 5 ,ply, '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: /4' z'/��S Policy#or Self-ins. Lic. #: 4 / ci GU Sc)3 ci 6 37/ 2 Expiration Date: 9 S/J G Di Job Site Address: 9 3g' ;?.- ` R-- City/State/Zip: Ss' fncC-"-N_ Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that 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 pa' s and enaldies o perjury that the information provided above is true and correct. Signature: ___til Date: 7 `)r S Phone#: �G� 3- 7 c2 3 ` c) ffOfficial use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # ling Authority(check one): Board of Health 20 Building Department 31:City/Town Clerk CO Electrical Inspector 51DPlumbing 'tor 6.0Other Person: Phone#: Commonwealth of Massachusetts ig, Division of Occupational Licensure Fos Board of Building Regulations and Standards Const i� i i 5o' rvisor Get CS-017539 c p i res: 06/06/2026 our THOMAS E I CKINELLO `" Exr 928 ROUTE 28 BLDG H SOUTH YARMOUTH 664 GU ?�• *rig° O� F0r `%(ILL (1183 SDI or ' Commissioner eve ____S„.‘„..L 02 Albk As always,Thanks Tom 3 f 41114110011110, i . / cn ►. X a XI 0 If a • C 4 4 Al • • 4. _.".4_ cue- ` Clarke, Kristin From: Inkley, Rosa Sent: Tuesday, April 22, 2025 9:42 AM To: Clarke, Kristin Subject: FW: Bass River Sports World. From:TOM NICKINELLO<tenick@aol.com> Sent:Tuesday, April 22, 2025 9:40 AM To: Inkley, Rosa <rinkley@yarmouth.ma.us> Subject: Bass River Sports World. Attention!:This email originates outside of the organization. Do not open attachments or click links unless you are sure this email is from a known sender and you know the content is safe. Call the sender to verify if unsure. Otherwise delete this email. Hi there. Thanks for all your help in the manner. Here is my license and a picture of the game room. I am replace 20 sheets on the front of the building. 1