HomeMy WebLinkAboutBLD-23-002256 Y 1 Office Use Only
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EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department RECEIVED
1146 Route 28 - ------ --,
South Yarmouth, MA 02664 OCT 26 2022
(508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS: BUILDING DEPARTMENT
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ASSESSOR'S INFORMATION:
Map: Parcel:
)
OWNER:TaS /M' / G�`l - (1/6 a� _,(1 )-J�.1 J e- - i' �z
NAME PRESENT ADDRESS TEL. # J
CONTRACTOR: J )/71'n r-] 5 �iT 1).-- 1)° \/\1 •-,nY,:s O' D �3 6—Z8O—pi'v?
NAME MAILING-ADDRESS TEL.r#
Residential ❑Commercial Est. Cost of Construction$ ✓,, 0 Ur Q—
/ _ J
!
Home Improvement Contractor Lic.# 6 ) '.,tj Construction Supervisor Lic.# -SS L - / 1 ar ri_.)--
Workman's Compensation Insurance: (check one)
❑ I am the homeowner ----46 I am the sole proprietor ❑ I have Worker's Compensation Insurance
Insurance Company Name: Worker's Comp.Policy#
WORK TO BE PERFORMED
Tent Duration (Fire Retardant Certificate attached?) Wood Stove
Siding: #of Squares Replacement windows:# / 0 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: J -.';/,C O — � .n i t-t.
Location of Facility
I declare under penalties of perjury that the stat- •-its h- -in 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 c-t : d for prosecution under M.G.L.Ch.268,Section 1.
Applicant's Signature: / t Date: 1 0 o2S
)a-D._,
Owners Signature(or attachment) ,77--.
a
—
Approved By: i ./. Date:
/ '". -1ZZ____
Building Offi ;0n'or d- ':%re) EMAIL ADDRE
Zoning District:
Historical District: ❑ Yes " No Flood Plain Zone: ❑ Yes 0 10
• Water Resource Prote tion District: Within 100 ft.o Wetlands:
0 Yes No 0 Yes ' No
The Commonwealth of Massachusetts
- /, Department of Industrial Accidents
• 9 M"''y 1 Congress Street, Suite 100
Boston, MA 02114-2017
ems..
14. �'s www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Lezibly
Name (Business/Organization/Individual): 1fr\A
Address:7O , //D (
City/State/Zip: w6-s7_7,1,r, ;,, 64 Phone #: 00- a 0
Are you an employer?Check the appropriate box: Type of project(required):
l.�I am a employer with employees(full and/or part-time).* 7. New construction
I am a sole proprietor or partnership and have no employees working for me in 8Eil Remodeling
any capacity.[No workers'comp. insurance required.]
3. I am a homeowner doing all work myself. [No workers'comp. insurance required.]t
9. El Demolition
10 Building addition
4.0 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 11.0 Electrical repairs or additions
proprietors with no employees.
12.Q Plumbing repairs or additions
5.11I I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs
These sub-contractors have employees and have workers'comp. insurance.:
14.E Other
6.1]We are a corporation and its officers have exercised their right of exemption per MGL c.
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:
Policy#or Self-ins. Lic. #: Expiration Date:
Job Site Address: City/State/Zip:
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$250.00 a
day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify un r pains and penalties of perjury that the information provided above is true and correct.
Signature: / Date: /
Phone#: � — eC) //7- O, ✓✓✓
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone#:
',13
: :. '
office of Consumer Affairs ;Ind Busy P �a �K '..
1000 Washington Strom-Suite 71
Boston, Ma :t`a tt 11,
Home Improvement Contractor Rejistration
:A SOW TN:WAS M. ,.--r;'_,zr, >, 1$P.O.SOX 1101
WEST DENNM.MA 026TO
cJ,Idate "#`.,,rs"s>i,1--d Rfit u='ss i-...ird
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HOME REPROVE:SENT CONTRACTOR
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101396 t314 ! Ydl�r start S6S.7, °`"�' "` > F
ROW"MA 02110
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THOMAS RITE.'
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HIC Registration Complaints
Registration 161295
Registrant THOMAS M. FUTEJ
Name THOMAS FUTEJ
Address 5 WINDWARD RD
City, State W. DENNIS, MA 02670
Zip
Expiration 03/14/2023
Date
Complaints Details
No complaints found for this registrant.
You can also view arbitration and Guaranty Fund history.
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10/25/22,3:49 PM
Details
Licensee Details
Demographic Information
Full Name: THOMAS M FUTEJ
Owner Name:
License Address Information
City: West Dennis
State: MA
Zipcode: 02670
Country: United States
License Information
License No: -..... __._.... _..._ .
CSSL-101165 License Type: Construction Supervisor Specialty
Profession: Building Licenses Date of Last Renewal: 9/29/2021
Issue Date: 9/27/2011 Expiration Date: 9/27/2023
License Status: Active Today's Date: 10/25/2022
Secondary License Type:
Doing Business As:
Status Change Reason: License Renewal
Prerequisite Information
Licensee: FUTEJ, THOMAS M
Relationship: Attribute Of
License No: CSSL-101165
Licensee: FUTEJ, THOMAS M
Relationship: Attribute Of
License No: CSSL-101165
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