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HomeMy WebLinkAboutBLDX-25-1023 O���g"""y \ O L — S v------- ® , L_____Oftice Use Only pcm,. fo y AUG 96 7025 1 (11 ount �=U,UZ °_✓� BUILDIN EPA TMENT By- _ EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 (508)398-2231 Ext.1261 CONSTRUCTION ADDRESS: i/.C.-Ca_ , OWNER: (MHS gMVO L° J OL\,r C's ko s\ U:-----!._`.C.O..^I1CT NAME PRES ITAT,yl)1](14S,_ „ems_ sts/� TEL F �-�r� CONTRACTOR: v.1 be— 1�rid' \\���AF L\A�1\1y �'`^�\C1 ,' 15-0 r,7 r / Z`e'� NAM, ^ J y I M17pir TEL.a /' fr__.._ __ EMAIL: ..jot!) //CLF—�1.►1 it.`n NA C 6_i t. �4� ek Residential (/ Commercial Est.Cost of-Construction S �) V"V5' Homeowner is Applicant?Yes No (/ a Home Improvement Contractor Lic.# Gib V f�''�IG Construction Supervisor Lic.II C-51s . b R q l h I.- WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate required) Wood Stove Siding: #of Squares 7 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-struct ores over 75 sears old require historical review 'The debris will be disposed of at: %jQ 9s -reaps.paps '' ' �i r I Location of Facility I declare under penalties of perjury that the statements herein contained are true and cement to the best of my knowledge and belief.I understand thenany false answerts) will be just cause ton denial revocation o[mvlicense prosecution for under M.O.L.Ch.268.Section I. !' V7 4. Applicant's Signature- �7�''"'1 Date-. ((/L - - N//c ers Signature for attachment) .).Q.1s-414(10 Date: . Ir -6- v Approved By: Date: 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 Please Print Legibly Name (Business/Organization/Individual): <JG (- Address: c G(Lez--tee-f-1 e r �041411 " g r City/State/Zip: 14142e,1- Yefir U wr Phone# J ' 77� Cf-Y-- Are you an employer?Check the appropriate box: Type of project(required): t.❑ 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. ID New construction 2. I am a sole proprietor or partner listed on the attached sheet. 7. ID Remodeling 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.❑ 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. Other 4(al y 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: 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of petjury that the information provided above is true and correct. Stature: `ty24....-- Z.11 Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(check one): 10Board of Health 20 Building Department 3❑City/Town Clerk 4.0 Electrical Inspector 5Elumbing Inspector 60Other Contact Person: Phone#: . , - Lieensee Details Demographic Information Full N ame:y... ....._._.____ _.__ _ JOSEPH E KiNG .____ _� ___. !Owner Name: • License Address Information City: West Yarmouth__ .._.-._.ter _�y ._..._�.-.__ �-� 'State: MA Zipcode: 02673• !Count : United States License Information jLicense No: CSSL-099166 License Type: Construction Supervisor Specialty_ 'Profession: Building Licenses Date of Last Renewal: 12/15/2023 c !Issue Date: -5/27/2008 Expiration Date: 1/24/2026 !License Status: Active Today's Date: 2/5/2024 ;Secondary License Type: !Doing Business As: !Status Change Reason: License Renewal Prere nisite Information °Licensee: KING, JOSEPFi E r..�.. .w��----a----- - ---- v -�d� .�.: �.__..� ..� Relationship: Attribute Of !License No: CSSL-099166 Licensee: KING, JOSEPH E - _-___,.._ ��a_ ... _____. Relationship: Attribute Of License No: CSSL-099166 _� _._� � � _�.M� No Available Documents ,...__.,._ ___ jflweCommo usetts aIthofMassacb` Division of Occupational Licensure Board of Building Regulations and Standards ConstructiQu e ;4: N., P �r Specialty • CSSL-099166 4 i of 6pires: 01/24/2024 JOSEPH E KING i 36 CHECKER$ERRYLi* WEST YARIUf�'f - �►TH IVIIq / l _ 3 Commissioner 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 JOSEPH E. KING Business Email Address Phone Number jomarlin@comcast.net 5087756448 HIC Registration Number Registration Effective Date 150889 May 5, 2024 Registration Status Registration Expiration Date Active May 4, 2026 Physical Address Mailing Address 36 CHECKERBERRY LN. 36 CHECKERBERRY LN. WEST YARMOUTH, MA 02673 WEST YARMOUTH, MA02673 US US Responsible Person 1 of 1 item Name v JOSEPH E KING 4 w _H Previous New Search 1 a4 4 , Enterprise Information Technology Accessibility Statement (https://www.mass.gov/info-details/home-improvement- contractor-hic-prt ram#ma-contractor-hub-accessibility-statement-) Office of Consumer Affairs and Business Regulation (https://mass.gov/consumer), Improve Our Site (https://forms.office.com/g/RzSgX7kkLD) Office of Consumer Affairs and Business Regulation I Home Improvement Contractor Program Need help? Call our Consumer Hotline at 617-973-8787 (te1:6179738787)or 888-283-3757(te1:8882833757).(toll-free) Monday and Wednesday, 9 a.m. -3 p.m. 1 Federal Street, Suite 0720, Boston, MA 02110-2012 © 2025 Commonwealth of Massachusetts.