HomeMy WebLinkAboutBLDX-25-524 ORECVED 4drittc.\ :::seo
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EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTHX--ZS _.5v.
Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664
(508)398-2231 Ext. 1261
CONSTRUCTION ADDRESS:
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OWNh,R:_ A2 ,tZ� �� tT7` 1 trlt�GL Zf- t c ✓isi./
NAME c PRESENT ADDRESS TEE. t' 21,3-63 1 -(�qq3/
CONTRACTORCV4(act/c4S 6S✓�,�aL1 S W 1TE1A1wdo9 - .�8-3 67`ST Zd
NAME MAILING ADDRES s. 04..it tgl O v-' ' TEL.
EMAIL: C t.{u L`` 5 r/N t„.'I 6 a S 0 o,.+ST12ucT)o�-( cl M A..t_ , Go
Er sidential ❑Commercial Est.Cost of Construction$ l JO 0
Homeowner is Applicant? Yes No V
Home Improvement Contractor Lic.# 136 l%064 Construction Supervisor Lie.#C,S —c Bc ' t o\
WORK TO BE PERFORMED
Tent Duration (Fire Retardant Certificate required) Wood Stove
4/\i 1 LI i, 1s✓
Siding: #of Squares Repl ement windows:# 1 Replacement doors: #
Rooting: #of Squares Insulation Temporary Mobile Home
Temporary Construction Trailer Demolition—interior only Demolition Raze Structure
Solar System ESS System Chimney Fence
*Please submit utility disconnect letters for electric&gas—structures over 75 years old require historical review
'The debris will be disposed of at: `/ L.v\p uT\k�-�1SFO S*
/ Location of Facility
1 declare under penalties of b • ments herein contained are true and correct to the best of my knowledge and belief. I understand that any false answer(s)
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will be just cause for denOrt f my li ,- .nd • •rosecution u . .G.L.Ch.268,Section 1.
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Applicant's Signatur A��'�'� Date: �j M
9COwnersSignature(, attachment) ,� `�"t-' "" 7/" Date: 4'/ 2-05 ,aL `
Approved By: Date:
Building Official(or designee)
Rev 6/24
f HE COMMC NWEP LTH OF MASSACHUSETTS
Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR
TYPE: Individual
Regstration Expiration
180664 12/10'2026
CHARLES SIMMONS
CHARLE S E.£,IMMO.\IS
1:56 WITCHWCOD RD
SOUTH YARMOUTH MA 02664
Undersecretary '
Commonwealth of Massachusetts
Division of Occupational Licensure
Board of Building Regulations and Standards
Cons�onivisor
8
CS-080901 �W lires: 01/25/2026
CHARLES E IMMON$E
156 WITCHC►D RD
SOIJTH Y:4RkpUTH MA 02664
?PA, O
Commissioner
The Commonwealth ofMassachusetts
Department of Industrial Accidents
Office of Investigations
-, Lafayette City Center
2 Avenue de Lafayette, Boston,MA 02111-1750
wwx.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print LeEibly
Name (Business/Organization/Individual): R Q e CGS
Address: I S(v �/�1 l-G.l t\Von _
City/State/ZipStk,Tt, ,4A,Houn} 62h4t Phone#: s5 -344 ? - S 7 Zen
Are you an employer?Chec the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. New construction
mployees(full and/or part-time).* have hired the sub-contractors
2. I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have g. ❑ Demolition
workingfor me in anycapacity. employees and have workers'
9. ❑Building addition
[No workers' comp.insurance comp.insurance..
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3. I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.]t c. 152,§1(4),and we have no
employees. [No workers' 13.�theri/1 f 14.1_,)
comp. insurance required.] l��- ��641
*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:ZS Vjp.tl. 1 c /Dt.e•VS t 4t L` U City/State/Zip_S. 4i2 Motjri r CR-Ca44
Attach a copy of the workers' compensation policy declaration p ee(showing the policy nu ber and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certi n pains and penalties o perjury that the information provided above is true and correct.
Si ature: Date: - z
Phone#: —7
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(check one):
IDBoard of Health 20 Building Department 30City/Town Clerk 4.0 Electrical Inspector 5aiumbing
Inspector 6.0Other
Contact Person: Phone#: