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Home My WebLink AboutBLDX-25-602 application Office Use Only 3- Ya9 % Y 6 4 .,4%i Permit#Migiii 4itA d Q -,_ �•�r Amount 3D, t0 4 l' �.0 P0RA1E� .- BOk—a 5--(4,6e____ EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH RECEIVED Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 MAY 12 2025 (508) 398-2 xt. 1261 • J "*".? BUILDING DEPARTMENT /� By: CONSTRUCTION ADDRESS: #/./_JJ - 1�/ 3 !/jj h, n w o /C� _ OWNER: h 1 PI 06 `-0►1 G E 14 1 �h Li Po D& NAME PRESENT ADDRESS U '• ) j TEL. # ,l�{ p� /� CONTRACTOR: Ml'A S r V P-U, � I I 0 \ ` J St Ii Alf ,5`v V-D� / I (2 j r�(� NAME _ MAILING ADDRESS D 6 TEL.# EMAIL: ' J A(L 1 /Ni Fe V%F 3 --S 3,„,,,I , Gol„ ,._.. d L_ =------r13residential 0 Commercial ❑Est.Cost of Construction$ ,sad -! Homeowner is Applicant? Yes NO'-se /� LS SL Home Improvement Contractor Lic.# 1 ) a 9 3 Construction Supervisor Lic.# i 0 ( 16 j WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate required) Wood Stove Siding: #of Squares Replacement windows:# / Replacement doors: # Roofing: #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: 51- J ..5 Ob. Location of Facility I declare under penalties of perjury that the sta ments herein 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 revoc 'o y li se and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: -3//2-2 ) Owners Signature(or attachment) Date: Approved By: Date: Building Official(or designee) Rev 6/24 The Commonwealth of Massachusetts —* Department of Industrial Accidents ,_ a Office of Investigations "�=rzt— Lafayette City Center 2 Avenue de Lafayette, Boston,MA 02111-1750 ',4 "e Je www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly 4 Name (Business/Organization/Individual): ) ��pS �s C1 C Address: - \\\D\ v City/State/Zip: O ,bV hone #: u 2-6 C ' IL) U Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. El New construction -2 I am a sole proprietor or partner- listed on the attached sheet. 7� Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.$ 9. ❑Building addition 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 11.0 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 13.❑ Other employees. [No workers' comp. insurance required.] *My 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 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 certify under the ai,and penalties of perjury that the information provide above is true and correct. Signature: Date: +. ), A.D Phone#: '^7 5,�, Official use only. Do not write in this area, to be completed by city or tower official. City or Town: Permit/License # Issuing Authority(check one): 10Board of Health 20 Building Department 3tCity/Town Clerk 4.0 Electrical Inspector 5Elumbing Inspector 6.0Other Contact Person: Phone#: 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: CSSL-WS-Windows and Siding Profession: Building Licenses Date of Last Renewal: 10/2/2023 Issue Date: 9/27/2011 Expiration Date: 9/27/2025 License Status: Active Today's Date: 5/12/2025 Secondary License Type: Doing Business As: Status Chan e Reason: License Renewal Prerequisite Information Licensee: FUTEJ,THOMAS M Relationship: Attribute Of License No: CSSL-101165 No Available Documents MASSACHUSETTS DRIVER'S LICENSE 01- ¥ ! . . : f< ! d 2\§ «4a/ . : g172I024 m s \ 3DOB� /1' : j«g& 09/27/1957 \ , . :« , . ! u_ __ . ° ° % a; . :m£ 2NE k ° i/UT7 . . . \2 ƒ\/�y� / � , � >a«m9N ^ ?d : ea49Ame 2 / \ fmBel &F mf-i /Ey aN � 5 �16 { 0�2�57 Contractor Loq in Home(/s/) An official website of the Commonwealth of Massachusetts Here's how you know Search Contractor Registration and History * indicates required field Always confirm that a contractor is registered before you hire one. Should you need assistance in the future,you will not be eligible for arbitration or the Guaranty Fund if the contractor you hire is not registered. Contractor Account Name THOMAS M. FUTEJ Business Email Address martinfutej57@gmail.com HIC Registration Number 161295 Registration Status Active Physical Address 5 WINDWARD RD W. DENNIS, MA 02670 US Phone Number 5082801402 Registration Effective Date March 15, 2025 Registration Expiration Date 9 P March 14, 2027 Mailing Address P.O. BOX 1101 WEST DENNIS, MA02670 US Responsible Person 1 of 1 item