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HomeMy WebLinkAboutBLDX-25-334 application 11 ,¢, y�-� Office Use Only O Permit# / tt Amount t� Ma " I.. ........ EXPRESS BUILDING PERMIT APPLICAIOCEIVEDI TOWN OF YARMOUTH �a /b_ 5 a2/ Yarmouth Building Department MAR 25 2025 1146 Route 28 South Yarmouth, MA 02664 BUILDING DEPARTMENT (508) 398-2231 Ext. 1261 f' S_12,Q \J, ari+�`r Qom/ ' CONSTRUCTION ADDRESS: 0 V ., �1 5.l� �,, OWNER: c çcMl GC . `I(k 54.". OI,Y'A'c.-" SC? 36 2 -9 281 NAME PRESENT ADDRESS TEL. # CONTRACTOR: ?ri5CO III l � .,Yr3 1 M.. ql Lkke v) el A9011 Oen'10 M S3� NAME G, 5 O MAILING ADDRESS TEL.# Q ap 3 7 EMAIL: e rffe-0 ba/ I L J t /, .6) co►'v►C A.54, rl e+- 0 Residential ommercial ❑ Est.Cost of Construction$ .53 000 / Homeowner is Applicant? Yes No } 9Home Improvement Contractor Lic.# 2.1 9,3 57 Construction Supervisor Lic.# © I Z WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate required) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # 3 Roofing: #of Squares i Insulation Temporary Mobile Home Temporary Construction Trailer Demolition—Interior only *Demolition Raze Structure �/� Solar System ESS System Chimney Fence �r /7' L//�-C--- *Please submit utility disconnect letters for electric&gas—structures over 75 years old require historical review er *The debris will be disposed of at: 5 ;J !� 6,_- 500 10 e h yl t, //1 4 Q Z 6 6 Q Location of Facility I declare under penalties of perju that the statements he ' contained are true and correct to the best of my knowledge and belief. 1 understand that any false answer(s) will be just cause for denial r r at of my 'tense nd sec io un r M.G.L.Ch.268,Section 1. I' 5[1.-- Applicant's Signature: Date: 'Lb Owners Signature(or attachment) /,i, Date: 3/ /2-A02_J Approved By: Date: Building Official(or designee) Rev 6/24 2\ The Commonwealth of Massachusetts Department of Industrial Accidents m . ,, —4( Office of Investigations ;1 Lafayette City Center (..4- 1 2 Avenue de Lafayette, Boston,MA 02111-1750 t -,,,, www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): er-^i '5 C 0 1 v , /d t r.s _Z #11e , Address: Li I (-- ,14 .e. V1i2 . City/State/Zip: b� �,v�, �✓� rlr1 �t 5 /11 �-- #: _..5. ,e— 23 7-- S-34/ Are you mployer? Check the appropriate box: Type of project(required): 1. am a employer with Z 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6 ❑ New construction 2.0 I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g. ❑ Demolition working for me in any capacity. employees and have workers' 9[No workers' comp. insurance comp. insurance.$ ❑ Building addition I required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.0 I am a homeowner doing all work officers have exercised their 1 I.❑ 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.n Other typo rr' I Oe L(C comp. insurance required.] I c G`e vv., _ *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. f�, Insurance Company Name: A i 1 r f• `s MO` O I'iJd 1 1^rj cJ r ct..in it CO v► y r Policy#or Self-ins. Lic. #: V.V.-Cr c -5D3 J I(j`—Z 2 y4 Expiration Date: c' I g /2-• d-L-S— Job Site Address: /00 1Z t^yS °e f V', City/State/Zip:q ,r-yh,v ( ar-1-- 02.67S` Attach a copy of the workers' compensa ' n 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 certif nder the pains and penalties of perjury that the information provided above is true and correct. Signature: - 6 ,p�2y�- Date: 31 I y /Z 0 Z S .-- Phone#: 57,V - -2__- _7 5-3 G 1 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): lDBoard of Health 20 Building Department 3❑City/Town Clerk 4.0 Electrical Inspector 50Plumbing Inspector 6.0Other Contact Person: Phone#: THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE.Corporation Registration Ezpitation 212357" i Q6/11i2026 PRISCO BUILDERS INC.' 4 PAUL A.PRISCO lr y 1s 41 LAKE DRIVE S.DENNIS, MA 02660 Undersecretary Commonwealth of Massachusetts j4 ,+ Division of Occupational Licensure - Board of Building�_Ryequlatio:is and Standards Constkul-ion SV7ervisor s CS-092742 1'tpires �:. 2: 2025 PAUL A PRISCO - .k 41 LAKE DRIVE ' SOUTH DENNIS MA 02660 :. e , Commissioner .,,>>�..� 1 . . THE COMMONWEALTH OF SSACHUSETTS Office of Consumer Affair5A Business Re N., HOME IMPROVE Regulation NT CONTRACTOR TYP :Individual Re istr ion iration 1 .41 08/04/2024 PRISCO BUILDS PAUL A.? ISCO 41 LA DR SOU DENNIS,MA 02660 `*�- :xlr..lc" Undersecretary