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.. ' %issue date
EXPRESS BUILDING PERMIT APPLICATJ pq t7 I ' .,.
TOWN OF YARMOUTH �.___. _._._._v�._ I 's
Yarmouth Building Department i
1146 Route 28 11G 3() ��1
South Yarmouth, MA 02664 `
(508) 398-2231 Ext. 1261 z Fwr4,
CONSTRUCTION ADDRESS: ‘OD Zk ZCJ / k6-s / fI R1,007,4(
ASSESSOR'S INFORMATION:
Map: Parcel:
OWNER: 6ere / /SC/3A/0 PIS L LC
NAME PRESENT ADDRESS TEL. #
CONTRACTOR: r.4I e6 .FIJ/6/2//1/6 (,QPP#9 /' PVC 5:01 6/9 607��
NAME MAILING ADDRESS TEL.#
El Residential %Commercial Est.Cost of Construction$ �CO
Home Improvement Contractor Lic.# /76 q 70 Construction Supervisor Lic.# 615-0 39
Workman's Compensation Insurance: (check one)
❑ I am the homeowner ❑ I am the sole proprietor ' have Worker's Compensation Insurance
Insurance Company Name: �✓�(ei�s Worker's Comp.Policy# a//i) f K 2 i, 204/,
WORK TO BE PERFORMED ,P a M/Egi0&
Tent Duration (Fire Retardant Certificate attached?) Wood Stove
Siding: #of Squares Replacement windows:# Replacement doors: #
Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation
Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing
*The debris will be disposed of at Mg riou I n ?NI
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 answer(s)
will be just cause for denial or revocation of my license and for prosecution under M.G.L.Ch.268,Section 1.
Applicant's Signature: Date: 9/ o742 /9
Owners Signature(or attachment) Date:
Approved By: E Date: 9-3 0—/
Building ial es' ee) DRESS:
Zoning District:
Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No
Water Resource Protection District: Within 100 ft.of Wetlands:
0 Yes 0 No 0 Yes 0 No
7
/_ The Commonwealth ofMassachusetts
��_w_,
,V,MI=ffl, Department of Industrial Accidents
e =;;,1,►_= q 1 Congress Street,Suite 100
_ #— Boston,MA 02114-2017
j—� www mass goy/dia
' Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Ora n• ation/Individual):TATRA BUILDING COMPANY INC.
Address: 1268 RTE 28
City/State/Zip:SOUTH YARMOUTH, MA 02664 phone#:(508)619-6073
Are you an employer?Check the appropriate box: Type of project(required):
1.❑✓ I am a employer with 4 employees(full and/or part-time).* 7. 0 New construction
2.0 I am a sole proprietor or partnership and have no employees working for me in 8. Q Remodeling
any capacity.[No workers'comp.insurance required.]
3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
9. 0✓ Demolition
10 Q Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions
proprietors with no employees.
12.0 Plumbing repairs or additions
5.173 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.11Roof repairs
These sub-contractors have employees and have workers'comp.insurance.
I
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other
152,§1(4),and we have no employees.[No workers'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:TRAVELERS
Policy#or Self-ins.Lic.#:6HUB1 K24420419 Expiration Date:03/15/2020
Job Site Address:590-604 RTE 28, WEST YARMOUTH, MA City/State/Zip:02673
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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.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 perjury that the information provided above is true and correct
Signature: Date: B/Z9/L0/9
Phone#:508.619.6073
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
07/18/2019 15:20 7813292834 POLITO INSURANCE PAGE 01/01
Tatra Building Company ir1t, a; 1268 Rte 28. South Yarmouth: MA 02664 e: Info@tarraco.vom pit: 1.833.468.2872
To:Town of Yarmouth / Building Dpt. Date:July 18t,2019
Owner Authorization
for
590-604 RTE 28 & 606-610 RTE 28, WEST YARMOUTH, MA
12 WINSLOW GRAY RD, WEST YARMOUTH, MA
Undersigned, owner(s)of the property located at 590-604 RTE 28&606-
610 Rte 28 and 12 Winslow Gray Rd.,West Yarmouth, MA authorize On
Kvietok(Tatra Building Company Inc.)to act on their behalf in regards to
obtaining necessary documents and filing for required permits with the Town
of Yarmouth, MA
Sincerely,
Chaya Rosenberg, Great Island Plaza LLC,trustee
Signature(s):
6(2.
Orr
Orale
G
Date Signed: 7-/f r` f
TATRA.1 . 833 .G o.Tatra