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Home My WebLink AboutBLDX-25-700 application ,rgYA Office Use Only 1104‘d, Permit# o y. ',:Amount 5(-466 Y RP EcDx- 5--7Cb EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department R E C 1146 Route 28 E /I E 0 South Yarmouth, MA 02664 MAY 2 g 1025 (508) 398-2231 Ext. 1261 BuiLDING CONSTRUCTION ADDRESS: 1 Gingerbread Lane Yarmouth Port MA By. DEPARTME, Betsy Hewlett 1 Gingerbread Lance Yarmouth Port 508-776-9098 OWNER: NAME PRESENT ADDRESS TEL. # CONTRACTOR: Alex Hazelton 665 Lincoln Street Duxbury MA 617-590-4402 NAME MAILING ADDRESS TEL.# EMAIL: alex@hazeltonbuilders.con l Residential ❑Commercial Cl Est.Cost of Construction$ $65000 Homeowner is Applicant? Yes No X Home Improvement Contractor Lic.# 163153 Construction Supervisor Lic.# CS-096503 WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate required) Wood Stove Siding: #of Squares Replacement windows:# ao, 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 tor electric& gas structures over 75 years old require historical reviesv *The debris will be disposed of at: Trojan Recycling Brockton MA 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 understand that any false answer(s) will be just cause for denial or revocation of my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: 5-28-25 Owners Signature(or attachment) EC;4 -Cti �'\—aS ri t,:l Date: 5-29-25 Approved By: JJ Date: Building Official(or designee) Rev 6/24 The Commonwealth of Massachusetts Department of Industrial Accidents qi) Office of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston,MA 02111-1750 Y & www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Alex Hazelton Address: 665 Lincoln Street City/State/Zip: Duxbury MA 02332 Phone #: 6175-04402 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. 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' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.: required.] 5. ElWe 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 employees. [No workers' 13.0 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. 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: 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 u r the pains and jury that the information provided above is true and correct. Signature: Date: 5-28-25 Phone#: 61 -590-4402 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 31:City/Town Clerk 4.0 Electrical Inspector 50Plumbing Inspector 6.0Other Contact Person: Phone#: Commonwealth of M 3chusetts Division of Occupational Licensure Board of Building Regulations and Standards ConstjI bn[BNIOriisor CS-096503 Y, Ely; :s: 12/10/2024 ALEXANDER))HAZELTON 665 LINCOLN%STREET DUXBURY M�t 02332 1 - � lb �� 4(11.1.Va?'' Commissioner ` &m( a_ , Licensee Details Demographic Information !Full Name: Alexander D Hazelton I wner Name: License Address Information ........... City: Duxbury State: MA Ripcode: 02332 (Country: United States License Information License No: CS-096503 License Type: Construction Supervisor Profession: Building Licenses Date of Last Renewal: 12/27/2024 ,Issue Date: 12/10/2010 Expiration Date: 12/10/2026 License Status: Active Today's Date: 5/29/2025 !Secondary License Type: Doing Business As: Hazelton Builders LLC !Status Change Reason: License Renewal Prerequisite Information No Prerequisite Information No Available Documents Contractor Log 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 ALEX HAZELTON Business Email Address alex@hazeltonbuilders.com HIC Registration Number 1 163153 Registration Status Active Physical Address 665 LINCOLN STREET DUXBURY, MA 02332 US Phone Number 6175904402 Registration Effective Date May 18, 2025 Registration Expiration Date May 17, 2027 Mailing Address 665 LINCOLN STREET DUXBURY, MA02332 US Responsible Person I1 of 1 item