BLD-23-003402 ( W AAA Office Use Only
,01..yqR
O" .H (JtJ0 5-0
Amount
$Y, Permit expires 180 days from
issue date
EXPRESS BUILDING PERMIT APPLICATIO
TOWN OF YARMOUTH ,._.___.._,RECEIVED
�_..___._r.m...._...-.-
Yarmouth Building Department DEC 19 2Q22
1146 Route 28
South Yarmouth, MA 02664 1
(508)398-2231 Ext. 1261 BUILDING DEPARTMENT
�(\ ( By
CONSTRUCTION ADDRESS: de—Di /\�' ' Ye_w t.1.2v 'e`t.
ASSESSOR'S INFORMATION:
Map: Parcel:
,
/ �. /La�� L�- l
OWNER: f \ \_. C .) a i. . /3 t� iIGJ I'C
r 1t: 71-1ES"NT ADDRFSS TEL. # Ll e/ {-7 2`74),_ .....
CONTRACTOR: lc, M LING RESS 3 •
EL.# W(J 97 ,Y9 5
C tesidential 0 Commercial , J Est.Cost of Construction$ /0 006,/0
Home Improvement Contractor Lic.#_ Construction Supervisor Lic.# C s l 06 06 T 3
Workman's Compensation Insurance: heck one)
0 I am the homeowner I am the sole proprietor 0 I have Worker's Compensation Insurance
Insurance Company Name: , \ Worker's Comp.Policy#
WORK TO BE PERFORMED
Tent Li Duration (Fire Retardant Certificate attached?) Wood Stove I I
Siding: #of Squares Replacement windows:# le) Replacement doors: #
Roofing: #of Squares (Ti)Remove existing*(max.2 layers) Insulation
I I Old Kings Highway/Historic Dist. IN)Replacing like for like Pool fencing
*The debris will be disposed of at: )7,,,,i,„4-Li 1 v-'� Q ,1 t ��
Location of Facility
.
I declv'e under penalties of per';orti Plat the s'.mer�t<her.i c newd are u ue Tarei correct to the best ci my knowledge and belief. I understand that any false answer(s)
will be.just cause for denial or revoca?ion of my lice , or pro 'ution under M.G.L.Ch.268,Section I.
Applicant's Signature: �� Date: i 49'/2 Z—
t Date: /2�y/,'I. `7,
Owners Signature(or attachment) /
Approved By: /
r Date: � ..--2:1L
Building Off ' or gnee) EMAIL ESS:
Zoning District:
Historical District: Yes No Flood Plain Zone: f Yes L No
Water Resource Protection District: Within 100 ft.of Wetlands:
1 Yes 1 No I Yes I' No
. The Commonwealth of Massachusetts
► " 1, Department of Industrial Accidents
, 1 Congress Street,Suite 100
Boston, MA 02114-2017
5,,�'� www.mass.gov/dia
\Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): A,,. ,,)
Address: Cj?�� ,�.��,,
City/State/Zip: title--t., 6 Phone#: 3 I 79 5 .2
Are you an employer?Check the appropriate box: Type of project(required):
1.0l am a employer with employees(full and/or part-time).* 7. ❑New construction
2.JI am a sole proprietor or partnership and have no employees working for me in 8. Remodeling
JY��y capacity.[No workers'comp.insurance required.]
9. ❑Demolition
3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
10 ❑Building cddition
4.01 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.❑Plumbing repairs or additions
5.01 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.:
6.0We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other ;t. ¢,` _�= >
152,§I(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.
tContractors 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. _
1 do hereby certify under the pal nd penalties of perjury that the information provided above is true and correct.
` --
Date: �Z .r /Cf. y'
Signature:( l-'` � , /L-�l_
Phone#:
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#:
c
®p Commonwealth of Massachusetts
s Division of Occupational Licensure
Board of Building Re ulations and Standards
Constructioj
�qr.1 &2 Family,
CSFA-060653 �, p
CHARLES AiOLMAN151c Aires:03/20/2023
O
9 MAY LANE'.,
SOUTH YARNIJ)UTH MA 02664
itt
•
Commissioner
i s 1% tre.pmica_,
•
ass. ov
„ z
HIC Registration Complaints
Registration 132454
Registrant CHARLES HOLMAN
Name CHARLES HOLMAN
Address 9 MAY LANE
City, State S. YARMOUTH, MA 02664
Zip
Expiration 09/21/2023
Date
Complaints Details
No complaints found for this registrant.
You can also view arbitration and Guaranty Fund history.
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