The URL can be used to link to this page

Home My WebLink AboutBLDX-25-699 application ' - RECEIVED n)y — coc'1/ Office Use Only 0� ,A� 1I� ' , 0` MAY 29 2025 Permit# C,/C Amount ,` B ARTMENT [ 4 '"FoRATE0�bA" By' -025-40gq EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 84 Mayflower Terrace OWNER: Tim Waites 84 Mayflower 617-584-7242 NAME PRESENT ADDRESS TEL. # CONTRACTOR: Project Managers CC LLC 15 Lexington LN Yarmouth port 5082461476 NAME MAILING ADDRESS TEL.# EMAIL: fairwaywilly@comcast.net li Residential ❑Commercial CIEst.Cost of Construction$28'000 Homeowner is Applicant? Yes No Home Improvement Contractor Lic.#208829 Construction Supervisor Lic.#CS-095981 WORK TO BE PERFORMED rl Tent Duration (Fire Retardant Certificate required) Wood Stove Siding: #of Squares 12 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 *The debris will be disposed of at:Yarmouth Landfill Location of Facility I declare under penalties of perjury that the stat eats • con-4ned are true and correct to the best of my knowledge and belief. I understand that any false answer(s) will be just c•uv ford ial;r revocati• of li d for p •:: Lion under M.G.LO 268,Section I./Applicant's Signature: ( _ Date: l Owners Signature(or attachment) Date: Approved By: Date: Building Official(or designee) Rev 6/24 `'-, The Commonwealth of Massachusetts Department of Industrial Accidents `; I '- Office of Investigations ,: ,t- "; Lafayette City Center . --; ', 2 Avenue de Lafayette, Boston,MA 02111-1750 www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/organization/Individual): Project Mangers CC LLC _ Address:15 Lexington Ln City/State/Zip:Yamiouthport MA 02675 Phone#:5082461476 Are you an employer? Check the appropriate box: Type of project(required): 1.❑ 1 am a employer with 3 4. ❑ I am a general contractor and I 6. ❑New construction employees (full and/or part-time).* have hired the sub-contractors listed on the attached sheet. 7. ❑ Remodeling 2.❑ I am a sole proprietor or partner- ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' comp. insurance. 9. ❑ Building addition [No workers' 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 11.0 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 Trim & sidewall employees. [No workers' 13.❑ Other 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:Travelers Policy#or Self-ins. Lic. #:6HUB-1 K86160-0-26 Expiration Date:02-25-26 Job Site Address: 84 Mayflower Terrace S Yarmouth City/State/Zip:S Yarmouth MA. 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 he pa' sad aloes of perjury hl the information provided above is true and correct. Signature: Date: ') I L / cc - Phone#: c—a ;- - 1* I 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): 1❑Board of Health 20 Building Department 31:City/Town Clerk 4.❑Electrical Inspector 5Elumbing Inspector 6.0Other Contact Person: Phone#: 13 _.�it ƒ A ¢ U \ \ 0 ID c / k z ! � . . .~` 0 M\ o o t ` \ ',f ® m § aC§ co � §{ � ° & o \ \ � .• N�0 oo 0 \ §_lg a I §I Q. § m k% { k ) = U $ 10 f )§ \& \ /§ v . 2 c ƒ] ■ E % )! � �� rm � a// \ / U V. ! ( } { ] co} !§ \E E� E ` ) m § ;� £ |) @ } ] & \\ ) E r \ E a i• r- LL E E= 0- e o { 2 E E' 7 - ' CD I \ £ E § JJ) ( \)