BLD-23-003604 C r
��� � �� ��� Office Use Only
'gyp f Permit#BULging
OI' y I1olz3 Amount,
Permit expires 180 days from
issue date
EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
RECEIVED
1146 Route 28
South Yarmouth, MA 02664 [DEC 3 �0z2
(508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS: 3 HOPE RD BUILDING DEPARTMENT
ASSESSOR'S INFORMATION:
Map: Parcel:
OWNER: Franklin Corey 38Reservoir RD. N.Attleborc
NAME PRESENT ADDRESS TEL. #
CONTRACTOR: Charles Holman 9 May Lane, S. Yarmouth 508-364-6737
NAME MAILING ADDRESS TEL,#
El Residential 0 Commercial Est.Cost of Construction$ 14,500
Home Improvement Contractor Lie.# 132454 Construction Supervisor Lie.#CSFA-060653
Workman's Compensation Insurance: (check one)
0 I am the homeowner El I am the sole proprietor 0 1 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 12 Replacement windows:# Replacement doors: #
Roofing: #of Squares (0)Remove existing*(max.2 layers) Insulation I I
Old Kings Highway/Historic Dist. (0)Replacing like for like Pool fencing I I
*The debris will be disposed of at: Yarmouth Transfer
Location of Facility
I declare under penalties of per' at the statements n 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 re ation of my 1 cense d for rosecution under M.G.L.Ch.268,Section I.
Applicant's Signature: Date: /2 —3 e) —2. Z.
Owners Signature(or attachment Date:
Approved By: Date: /` ^Z
Building Offici or ignee EMAIL DRESS:
Zoning District:
Historical District: Yes No Flood Plain Zone: Yes No
Water Resource Protection District: Within 100 ft.of Wetlands:
Yes No Yes No
or
411) Commonwealth of Massachusetts
Division of Occupational Licensure
Board of Building R7qulations and Standards
Constructioctig4enilklf 1 &2 Family
CSFA-060653 7 spires:03/20/2023;
CHARLES ApOLNI i
9 MAY LANE, s* I • 7.."
SOUTH YARNii3U a
.„
•(1,47*kvisiiiir
"
Commissioner daeG A'. 'Eltnata...
• Y •
•
•
•
•
•
i
. The Commonwealth of Massachusetts
I 4-, ,IMIIMI 1 Department of Industrial Accidents
ium iii I Congress Street, Suite 100
. Boston, MA 02114-2017
` �•' www.mass.go v/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): Charles Holman
Address: 9 May Lane
City/State/Zip:S. Yarmouth, MA Phone #: 508-398-8937
Are you an employer?Check the appropriate box:
Type of project(required):
1.01 am a employer with employees(full and/or part-time).* 7. ❑New construction
2.w am a sole proprietor or partnership and have no employees working for me in 8. ® Remodeling
ny capacity.[No workers'comp. insurance required.]
3. I am a homeowner doing all work myself. t 9. ❑Demolition
❑ y [No workers'comp. insurance required.]
4.0 I am a homeowner and will be hiring contractors to conduct all work on m Yproperty. I will 10❑Building addition
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.E Other siding
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 certi under the pains qpd penalties of perjury that the information provided above is true and correct.
Signature: — ---1—__ Date:1;0 7 Z
Phone#: 508-3987
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
b. Other
Contact Person: Phone#:
Y if
x
Mass.gov
I
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.
Back To Search
d
f
C
0.71
Lii ...„,,,,,,..c., ....,. ...,,,,,,,,,,-
,,,,.„, „...4., ,,
il
�. -
�i` ,- 1 ', ff
.\c- , 4,,.,
.,„
11 ..
�:
ci ....,„„ ,.
t,,,,. , -,,,,..„,) i ,.
NJ
is,,, .,,,,,) -
,i
77*.",,,, ,,,,, I 7 „..........
.. .§. :,./ 7:t--
1‘4, .„.„-...„:.„.,,, .:,....,
- ... ,. ,
y
.r - t