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Home My WebLink AboutBLDX-25-1242 ,cg Y4"ar RECEIVED !, (yoke Use Only �� . [ sFp — — cn Pntau— S�34a l �17 2025 1 ,mWnt 5 p— .o% BUILDING DEPARTMENT i By. EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 (^/ (508)398-2231 Ext. 1261 �{ CONSTRUCTION ADDRESS: S 5 `erm/QX S r YI a i I /if tyw�,,��1, (� ��1\ �A (�,� /y, / i1 a�a1vllsO�,aa GXavr..:a (�Q%, OWNER} s`O/ Cora lbe Pti.n?D(.1neww[ 01101 /" 1 e -1ipo 9 q -i q \AAIF PRI:SENT ADDRESS TEL _ ,L,�'p, CONTRACTOR )S W? Y • —910,41, 7 "Q.U.RN t9 6. 6WOO Y UYt- .UIF: ,I511 INS,.ADDRESS TEL.. 1 —991-o 8t2-b EMAII m;_ _d t45 e c y, _Residential s...."- ..:Commercial Est.Cost of Construction S 2._ +01:0 Homeowner is Applicant? 1'es No t/ /�• -1 a Home Improvement Contractor Lic.# t f 2"I Construction Supers isor Lic.# 0 ki e)3 3/6 WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate required) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # 2- Roofing: #of Squares Insulation Temporary Mobile Home Temporary.Construction Trailer Demolition-Interior only *Demolition Raze Structure Solar System ESS System Chimney Fence "Please submit utility disconnect letters for electric&gas-structures over 75 years old require historical resless •The debris will he disposed of at 41( vi. �044A It YP � 11 Locationn of Facility I declare under penalties of perjury that the statements herein contained are true and correct to the best of my knowledge and beliet.I understand that any false answensl I will be just cause for denial or revocation of my license a9d for prosecution under I I i I..Ch.26%.Section I I. �' ,f Applicant's Signature. ttJiA �(, `(/�(ZI ,'�n/'V Date: C�PY/1/11 � Owners Signature(or attachment)//�' `�liN'/ Date:-7—`"tat i(e ° °l3 I Appmsed By: Date: Building Official for designee) Res h 24 The Commonwealth of Massachusetts _. Department of Industrial Accidents o ►_ Office of Investigations Lafayette City Center ZAFil 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 (Business/Organization/Individual):Name {cet a s J U . DAmett.To , .- ,?.tm'ad -e, 4 C Address: 'O, {per x 1 •-f City/State/Zip:W K(, Ylwm, � ' ' Q ' Phone #: " CPI - 0 e/04 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. LIE 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.: 9. ❑ Building addition required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' right of exemption per MGL Ys comp. 12.❑ Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other e1 4-As 1� 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: ke Sktr04. c_ft 1 1, Policy#or Self-ins. Lic. #: W ti.li- ¶pU S 0 0 1�i (7'0 "1" Expiration Date: t?i`I ei 1 40 .- Job Site Address: Rit --3 1ett/ City/StatelZip:tI/H01.41�1 yW 0 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: bemu• C) Date:cee, r 6/ 26 9,g Phone#: 779 - q1`i or fob 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 3tJCity/Town Clerk 4.0 Electrical Inspector 50Plumbing Inspector 61:Other Phone#: Contact Person: r s 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 ii/Vititteq4- bzoi i"6 Update Address and Return Card. IV Commonwealth of Massachusetts Division of Occupational Licensure Board of Building Regulations and Standards F Construct r1 & 2 Famiiy ;CSFA-048338 apires: 01/22/2026 MICHAEL J IZANGELO P.O. BOX 144', WEST HYANt IISPORT MA 02672 '' _ Commissioner r ew,,f. s.�_