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22-EB026 33 Squirrel Run RoadRECEIVE MAR 10 2027 YiAFwI+ 06'l F, nl o KING'S HIGHV C BUILDING PERMIT APPLICATION TOVirN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 33 Squirrel Run Road ASSESSOR'S INFORNIATION: Office Use Only Permitff Amount 'S V Permit expires 18o days from Map: 123 Parcel: 77 OWNER: Lynne Clancy 33 Squirrel Run Road Yarmouthport, MA NAME PRESENT ADDRESS TEL. CONTRACTOR: Mark Clancy P.O. Box 249, South DenniE 5082404404 NAME ElResidential 0 Commercial Home Improvement Contractor Lie. # 179722 Workman's Compensation Insurance: (check one) MAILING ADDRESS TEL # Est Cost of Construction $15, 000 Construction Supervisor Lie, 9CS-057138 0 1 am the homeowner 0 1 am the sole proprietor 0 1 have Worker's Compensation Insurance Insurance Company Name: Associated Employers Iris. Worker's Comp. Policy-# WCC500501382022A WORK TO BE PERFORMED Tent El Duration (Fire Retardant Certificate attached?) Wood Stove Siding: # of Squares Replacement windows: # Replacement doors: Roofing: 4 of Squares ([V�,) Remove existing' (inax. 2 layers) Insulation Old Kings Highway/Historic Dist. (E} Replacing like for like ��, Pool fencing ��w�c( *The debris will be disposed of at: S&J EXco, 200 Great Western Rad, South Dennis MA 02660 Location of Facility I declare under penalties of per t 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 Beni ] o�r catt�f my license and for prosecution under M.G.L. Ch. 258, Section L Applicants Signature: v Date: % a (!� 0 7 Z Owners Signature (or at ch en Approved By: Date: Building Official (or desi-nee) EMAIL ADDRESS: Zoning District: Historical District: Yes No Flood Plain Zone: Yes No Water Resource Protection District: Within 100 It. of Wetlands: Yes No Yes No ,; _U0`16 The Commonwealth of Massachusetts RECEIVED Department of Industrial Accidents I Congress Street, Suite 100 MAR 1 p 2x22 K Boston, MA 0.2114-2017 wti Q. ' www mass.gov/dia OLD KING' HIGHWAY W'orkers' Compensation Insurance Affidavit: Builders/Contraetors/Electricians/Plumbers. TO BE FILET) WITH THE PERMITTING AtrfHORITY. Applicant Information Please Print Leaibi Name (Business/OrganizatiorAndividual): Clancy & Castano LLC Address: P.O. Box 249, 17 American Way City/State/Zip: South Dennis, MA 02660 Are you an employer? Check the appropriate box: Phone #: 6082404404 I.E]M I am a employer with 3 employees (full and/or part-time).* 2.F�3 am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 4,711 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 proprietors with no employees. 5.FJI am a general contractor and I have hired the sub -contractors listed on the attached sheet These sub -contractors have employees and have workers' comp. insurance.# 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § I (4), and we have no employees. [No workers' comp. insurance required.) Type of project (required): 7. ❑ New construction 8. ❑ Remodeling 9. ❑ Demolition I0 Building addition 1 l.E]Electrical repairs or additions 12. ❑ Plumbing repairs or additions 13. Q Roof repairs 14. E] Other r.,,y appl1QUUL Lna[ cnecxs oox IF i must also ril I out the section below showing their workers' compensation policy information. Y 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 subcontractors 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: Associated Employers Insurance Co. Policy # or Self -ins. Lic. #: WCC500501382022A Expiration Date: I A /2023 Job Site Address:33 Squirrel Run Road city/State/Zip: Yarmouthport 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 cerci the - s and penalties of perjury that the information provided above is true and correct Si nature: Date: 3/10/2022 Phone #: 50 404 Official use only. Do not write in this area, to be completed by city or town official. City or Town: PermitfLicense # Issuing Authority (circle one): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: __� Rift,s MAR 10 2022 f ArMIVIQu i I ,-- ... _ . I ,ti Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: LLC CLANCY & CASTANO LLC ori Registration: 179722 P. O. BOX 249Expiration: 09/01/2022 SOUTH DENNIS, MA 02660 20M-05/77 .��r� �a�a�renrrcae«ti�o�,%Jfo::.s��fr�e�l•� Office of Consumer Affairs & Business Regulation ROME IMPROVEMENT CONTRACTOR TrYPE; LLC Re istration Expiration 1197_2_ . 09/01/2022 CLANCY & CASTAN MICHAEL CASTAfV 17 AMERICAN UNIT 3 SOUTH DENNIS, MA 02660 ;��' W4 4 -le i �� Undersecretary Update Address and Return Card Registration valid for individual use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, MA 02118 Not valid }W 60yt ilAnature