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Home My WebLink AboutBLDX-25-312 application Office Use Only Oo Perot#d.,< 9y . y) Amount q U c yC�4POR11=�``� D `- 5-3id-- EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 RECEIVED South Yarmouth, MA 02664 `/ (5088) 398-2231 Ext. 1261 MAR 21 2025 CONSTRUCTION ADDRESS: 7?a1 / `lQ7(J 57- rmerI44./ BUILDING DEPARTMENT ey — -- OWNER:Zg 4iI /SOL7�CfM.. 2/ r3Iyev/o,)C l4. Cs v 7)e /, .\III L 7 J� PRESH-NpT�ADDRESS , ��jTE/L ;-- / CONTRACTOR:A ei / J . ..iJA '•D. p ,�� W. CIhq/` ] /)j4. 77Y -q99 -Og b NA\TI ' ',` MAIL ING:\DURISS / TEL.n EMAIL: 1(1p dit he `�9 V(esidential Commercial Est.Cost of Construction `6; am 20J OZYU. Homeowner is Applicant? Yes No Y Home Improvement Contractor Lic.# )(2. -L 77 _Construction Supervisor Lic.# b 7 e-3 j WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate required) Wood Stove Siding: #of Squares (0- 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 ti // . *Please submit utility disconnect letters for electric& gas -structures user 75 sears old a cyuire histut leap rr%lets *The debris will be disposed of at: v`4A r' _ 4'II / &d� 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 he just cause tier denial or revocation of my I ense and for prosecution under M.G.L.('h.268.Section I. �� 4,� 4 /, �f ij n�, 2/ 2,o Z� Applicant'.Sip!naturr �rl/U'L(�r (� rGf� Date �'/YNI� ( nnSignature [a tiers Signature(or JfChltlrntl 7eAY� Uatr: a 2 l�_//-1_- Approved By: Date: Building Official for designee) Res 6 24 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ; Lafayette City Center Ulf 2 Avenue de Lafayette, Boston,MA 02111-1750 www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information 1D Please Print Legibly / Name (Business/Organization/Individual):f}L( 2 p p/ J_ l�G h/E l2Wq Rem Address:/1.% Cron t o, i)P 13p 12�Q City/State/Zip: Cott. V t,t *4, O NCO aZ Phone#: `77'i ' 4/q'f - (,F66. Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I employees (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. 1Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp.insurance.: required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.El I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.0 Other 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: Le011.t YU3 Ai$r ter cvM.ra- Policy#or Self-ins. Lic. #: 1,5( e -61 -5!,D 613 3 - R( ) Expiration Date: 1?i f 14(Z$ Job Site Address: 7 y/ let)ld Zd 571. 7t2Y f)t, tl/c City/State/Zip: C6t,f/fl.aZ(f t(i 04- 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 pains and penalties of pedury that the information provided above is true and correct. Signature7^}W4 .P &RI €O Date: WI WI,- 2 e Z S Phone#: 175 �f C1`l r3 0. Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License # Issuing Authority(check one): 10Board of Health 212 Building Department 3C]City/Town Clerk 4.0 Electrical Inspector 50Plumbing Inspector 6.0Other Contact Person: Phone#: Commonwealth of Mas L censure I chusetts Division of Occupational 1. Board of Building Re��iations8 and2 StandardsFamily _j,g tan Constructi !°. r pires:01127J2026 I .CSPA-048338 r '` MICHAEL J i NGELO P.O.BOX 14 POR7 MA 026T2? >`r 244aiiii., \ WEST HYANN1,t '4Ul,IN,t 1'itit,_ ,, Commissioner _fie\j. t— THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Corporation MICHAEL J. DANGELO BUILDING& REMODELING, INC. Registration: 112977 P.O. BOX 144 Expiration: 03/08/2026 WEST HYANNISPORT, MA 02672 qAppitteed.. hictiff6 Update Address and Return Card.