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Home My WebLink AboutBLD-23-000690 ui'•YgR- C60 Le Office Use Only ' 'C 4.. ' ' l ��rJ (Permit# L' #373?) fO/�.,'�, r H Amount '�` MATTAIM LSE �' '1 ' �` "`°"' mod,' !Permit expires 180 days from E� >:::". ;issue date 6 14)—a.3 --0/0 4100 EXPRESS BUILDING PERMIT APPLICATIC dE C E I 'V E D TOWN OF YARMOUTH • Yarmouth Building Department 1146 Route 28 AUG 10 2022 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 BUILDING DEPARTMENT By: • CONSTRUCTION ADDRESS: 7 / -..rP e-- Al'‘c..1-- (?0 (Z ASSESSOR'S INFORMATION: Map: Parcel: OWNER: )- O© kc /3t,J s ,LJ 't Act 4.1.9 $?l-; a? 'c. o NAME PRESENT ADDRESS TEL. # CONTRACT pc> N. < )(4 M uti i"-/-?j OA) AS T 4L e )N,,S J 0 S' - - 4,.7 f > 1 NAME MAILING ADDRESS TEL.# Residential ❑Commercial Est.Cost of Construction$ �j a 00 i ' .--- Home Improvement Contractor Lic.# J�' '7/ a Construction Supervisor Lic.# , ➢7 Workman's Compensation Insurance: (check one) , V y .2 d`s ❑ I am the homeowner ❑ I am the sole proprietor . 1 have Worker's Compensation Insurance Insurance Company Name: A, 1 VI.V a orker's Comp.Policy# �d / d. WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares J 6 Replacement windows:# /D 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: yig k ry1 a t I—] ) 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 and rstand that any false answer(s) will be just cause for evocation for prosecution under M.G.L.Ch.268,Section 1. ) q Applicant's Signature: G-ti 4**' Date: l/Jo ... Owners Signature(or attachment) P(, M)✓ Date: g/4/2-D— ,.,Approved By: .. Q Date: ter I6'' 4,4 Building 0 icial(or designee) EMAIL ADDRESS: Zoning District: Historical District: ❑ Yes D. No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes ❑ No • • \ • The Commonwealth of Massachusetts ice,,, , Wes► Department of Industrial Accidents =��1� 1 Congress Street, Suite 100 stili►, b =_ `- Boston, MA 02114-2017 .;_�•`�' www.mass.gov/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): '�,-)� ; ' PI NA j N Address: r?C).),, S—I-- 4-0-Y.-s-1-----_ u:, S i a Y1!� City/State/Zip: 6-2 O -- -j Phone #: --� -a� —73 6 "7 - ,5' �,S Are you an employer?Check the appropriate box: Type of project (required): 1 I am a employer with / employees(full and/or part-time).* — 7. Ne construction 2.0 I am a sole proprietor or partnership and have no employees working for me in any capacity.[No workers'comp.insurance required.] 8 emodeling 3.0 I am a homeowner doing all work myself. 9. ❑ Demolition y [No workers'comp. insurance required.]t 4.C I am a homeowner and will be hiring contractors to conduct all work on myProPrty e I will 10 n Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.Q Electrical repairs or additions proprietors with no employees. - 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 12.[1]Plumbing repairs or additions These sub-contractors have employees and have workers'comp. insurance.t 13 ❑Roof repairs 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: .1-- h'l. ,l'1 (-) + U A Policy#or Self-ins. Lic. #: .S 0 / 1 Q. 7 Expiration Date: Job Site Address: �:� S?h ,.J ?.,)r— '�j� City/State/Zip: . Attach a copy of the workers' compensation policydeclaration page(showing !��l� a —�l �'73 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 her certify der the pains and penalties of perjury that the information provided above i true'-and correct. Sign atu ---� Date: 9 /'Oii Phone#:LS 6 7 3 4 7 — ,5 2Q'---1 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#: Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Construction,&tI4/ISae1 & 2 Family CSFA-074205t yires 12/31/2022 DAVID L DADNIUN 43 POND STREET 73,4 WEST DENNIS MA 02 f $ :- �r.x . fl/S'S °lOZ� � Commissioner dad f. `t Erma a�. •�% �/'/iJl�J!'rU'fp/!�/'f.-��ili-i!/J�illf��l - _.._..-- Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Individual before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 128718 08./24/2023 1000 Washington Street -Suite 710 DAVID DADMUN Boston,MA 02118 D/B/A D.L.DADMUN CUSTOM BUILDERS DAVID L.DADMUN , 43 POND S T UNIT 7 !� W.DENNIS,MA 02.670 Not valid without signature Undersecretary