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Home My WebLink AboutBLDX-25-1377 - RECEIVED Office Use Only 3�° YARD �-A S /3 '9 OCT'15 2025 et:y .\mount • •^ BUILDING DEPARTMENT I ny EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 (508)398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 7( /0 /p Pv i'.,I _. .__._ OwNER:& N I6 'Al `� PRESENT ADDRESS TEL.p CONTRACTOR:/rI i d1QeL_✓• I n ids,__ Pa ea,fY 40 iS�"a�v,+�. `7`2Y-94N-0E3 04 y�� \\\II I \I\II.I\G\DURI,SS f TEL.x EM:\II �^ i I d foce t1 4UD.e&14- / �/ tlitesidential I -Commercial Est.Cost of Construction S (o!< Homeowner is Applicant? Ves No Home Improvement Contractor 1.ic.# /I 24 7-7 Construction Supervisor Lic.# OV 8 5/0 WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate required) Wood Stove Siding: #of Squares Replacement windows:# I?.. k,/ Replacement doors: # Roofing: #of Squares Insulation Temporary Mobile Home Temporary.Construction Trailer Demolition-Interior only 'Demolition Raze Structure I Solar System ESS System Chimney Fence 'Please submit utility disconnect letters for electric&gas-structures over 75 years old require historical resicss 'The debris will be disposed of at: lA1McuilUfn N"P 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 answensl will be just cause lire denial or revocation(linty license and for prosecution under M.ti L.Ch.268.Section I. Applicant',Signature. Dale:__ ^7 / Owners Signature(or a)tachmentl‹ ,w.� L�1 �� Dale: le/it//262.N -\ppmsed Its. I Date: Building Official for designee) Res 6 24 • •r a \ • • 1 - 1 The Common wealth of Massachusetts Department of Industrial Accidents 1111111111 - — _',. ►- Office of Investigations ram= ems Lafayette City Center mat. _ cy•_ 2 Avenue de Lafayette, Boston, MA 02111-1750 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): ilbjelad,/ J ,vii,dQ W4 d G1(4(401; 4AC- - Address: PD. 6v x /tiy City/State/Zip:ti /Lggnn;Sb vi- 44 l a6 7. - 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 mployees (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 working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.x 9. ❑ Building addition required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 11.❑ 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.❑ Other�dlO rep kk ti/a4 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: LeoM4I 414216t,I')G¢- Policy# or Self-ins. Lic. #: bet -6Z€) -cop b 7 33 " 2034314 C) ) Expiration Date: 17)i 4 )24--- diP°' st- So.4-I 1,lw0 -44 A Job Site Address: / City/State/Zi : S o•1 �h 14'W� +i6 p�� / P 4( 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. Signature: 114,4.11,14,,40(1i� e%% Date: t: /0 -O 2 c Phone #: '7) y- 0g4 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): 1❑Board of Health 20 Building Department 31:City/Town Clerk 4.1:Electrical Inspector 51alumbing Inspector 6.0Other Contact Person: Phone #: 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 Registration: 112977 MICHAEL J. DANGELO BUILDING & REMODELING, INC. Expiration: 03/08/2026 P.O. BOX 144 WEST HYANNISPORT, MA 02672 77uu& 4,t Update Address and Return Card. Commonwealth of Massachusetts Division of Occupational Licensure Board of Building Regulations and Standards H ' =,onstructio9:46pet rr 1 & 2 Family c9 ,CSFA-048338 xpires: 01/22/2026 " MICHAEL J TANGELO =f P.O. BOX 14 WEST HYANIII✓SPORT MA 02672 t_ tr>I.pvti`� Commissioner t �iS