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Home My WebLink AboutBLDX-25-930 Office Use Only O4 Yo\ Permit# yt+l t; Amount %V 1 0 H� �'1-cONPORAT lO�'�A' EXPRESS BUILDING PERMIT APPLICATI 1 l', E C V E .. TOWN OF YARMOUTH Yarmouth Building Department JUL 17 2025 1146 Route 28 South Yarmouth, MA 02664 BU e • • - ENT (508) 398-2231 Ext. 1261 6y d CONSTRUCTION ADDRESS: l ZOO gOO1E Z g t SeU l µ \/A�'!l4- OWNER: DO* L PrI Jo t19 Cr{t1SiaPij L '3 s 1 Poido -i 5v' 237-63z 3 NAME PRESENT ADDRESS b (� TEL. # CONTRACTOR: b tl 21(� 7� ►�1�ejz C� ( 4 I J a., Yam( I3 YQAO ct 6-0 6 cc q Sc NAME MAILING ADDRESS TEL.# EMAIL: 0.V 1� k .4 644, 1.,/� . K1 'f o Residential 'Commercial 4st.Cost of Construction$ /COO Homeowner is Applicant? Yes No V Home Improvement Contractor Lic.# f 6 Construction Supervisor Lic.# 10 3 V I WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate required) Wood Stove Siding: #of Squares 6 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: l —d'1 TE.- lVl(51 t- 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 revoc ion of my li se and for prosecution under M.G.L.Ch.268,Section 1. ,{ Applicant's Signature: - +"l Date: 7/1 /39 Owners Signature(or attachment) Date: 7 ///O /'�� Approved By: Date: 111 Building Official(or designee) Rev 6/24 The Commonwealth of Massachusetts Department of Industrial Accidents : ►_�:� Office of Investigations 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 (r Please Print Legibly Name (Business/Organization/Individual): 6“--€1ZC C5l/1 Address: 6C C '4I0 J' Cj City/State/Zip: 1c ✓ 1.4 rZrQ � Phone#: J D o a '{ � 14)0 c 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 6. New construction employees (full and/or part-time).* have hired the sub-contractors 2.10 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. ❑ 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' 13.0 Other 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. 1 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 nder the airs and penalties of perjury that the information provided above is t ue and correct Signature: Date: 7>6 Z�Phone#: CO 3 J —[ q 3 $' 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): 10Board of Health 20 Building Department 3ElCity/Town Clerk 4.0 Electrical Inspector 50Plumbing Inspector 6.❑Other Contact Person: Phone#: rt !h'�.?'..r� 12UOISSIUILUOo ,``�r'r a r, •1 1 ZO VI 2131SM3218 6£9 OVOd 213)11VM 99 ar`113sd)1 r A8VO . ,., 7617£01.-SO SZOZIS0I60.sand �.� u ?Zsuo0 i0s!AJ SI i-� splepuelS pue suollel 6a21 6wplm8;o pJeo8 ainsuaoll Ieuopedn330 fo uoistAia114 s37asnUoessew io tpleamuowwo0 THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs and Business Regulation 1000 Washington Street-Suite 710 Boston,Massachusetts 02118 Home Improvement Contractor Registration Type: Individual Registration: 189692 GARY KAISER Expiration: 11/14/2025 D/B/A KASER HOME IMPROVEMENT 65 WALKER ROAD BREWSTER,MA 02631 Update Address and Return Card. THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs 8 Business Regulation Registration valid for individual use only before the HOME IMPROVEMENT CONTRACTOR expiration date.If found return to: TYPE:Individual Office cl Consumer Affairs and Business Pegulation Registration Fsniration 1000 Washington Street-Suite 710 189692 11/14/2025 Boston,MA 02118 GARY KAISER D/8/A KASER HOME IMPROVEMENT GARY KASER 65 WALKER ROAD BREWSTER.MA 02631 Undersecretary Not va d w'hout signature