HomeMy WebLinkAboutBLDX-25-1081 Office Use Only
0 Permit#
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EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS: 3 7 i-1 1 S' 1 C./4?&. i d ..r- (/3-- S-1 0--_
OWNERDj=64.I t c t!.C� C 16- 37�t tS �"L- �u�'� \'1`r►'�' /p U( i 1 —
NAME PRESENT ADDRESS TEL. 73_ 46
CONTRACTOR: "� • 4- \ u 4.1 Tr}--
C14 VC/
ME AILING RESS TEL. e _ 367 _S7Z0
EMAIL(E j 11) 'LIS Cv-1 S 1_1)U O`,1 Q �p
lie sidential ❑Commercial
Est.Cost of Construction$ 5) Q Cr)a
Homeowner is Applicant? Yes Not/ e�
Home Improvement Contractor Lie.# t86(P 64 Construction Supervisor Lie.# C S !0,8 CS 1 a )
WORK TO BE PERFORMED
Tent Duration (Fire Retardant Certificate required) Wood Stove
Siding: #of Squares Replacement windows:# Replacement doors: # I
Roofing: #of Squares Insulation Temporary Mobile Home
Temporary Construction Trailer Demolition—Interior only Demolition Raze Structure
'so c_16_1cc4-4, (1x66 )
Solar System ESS System Chimney Fence
'Tk..Ac�r/eui/
*Please submit utility disconnect letters for electric&gas—structures over 75 years old r quire historical review
*The debris will be disposed of at: A.A is6 U 0 1— �j
LocatiSn of Facility
1 declare under penalties of that a 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 deni or r o on of ' ern secution under M.G.L.Ch.268,Section 1.
Applicant's Signature Date: —ill
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Owners Signature(or attachmc t� Date: ' nY eJ r l p7 S
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A roved By: /7�
Date:
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Building Official(or designee)
Rev 6/24
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the Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
17; - j 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 Le ibl
Name(Business/Organization/Individual)f`
Address: J Sd Li 1-1 -l;►k-7Dc>c �p _
City/State/Zip: S o26 Phone#:_5a
Are you an employer/ heck the appropriate box: Type of project(required):
1.❑I am a employer with 4.0 I am a general contractor and 1
,ortiployees(full and/or part-time).' have hired the sub-contractors 6. ❑New construction
2.wi I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling
ship and have no employees These sub-contractors have 8. 0 Demolition
workingfor me in anycapacity. employees and have workers'
9. 0 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 11.0 Plumbing repairs or additions
myself.[No workers'comp. right of exemption per MGL
ys p insurance required.]' c.152,§1(4),and we have no 12.❑ f repairs
employees.[No workers' 13. Othertet/C�` /
comp.insurance required.] 1- ' t-fr /✓(tit/
..Any applicant that checks box#1 must also till out the section below showing their workers'compensation policy information.
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.lithe subcontractors have employees,they must provide their workers'comp policy number.
Jam 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:S7`71:1A 1.11 STcc_. — City/State/Zip: ,ztd -f'4(A-. 6 C.
Attach a copy of the workers'compensation policy declaration page(showing the policy num r 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 S 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 t for insurance coverage verification.
1 do hereby ce fy u nobles o perjury that the information provided above is true and correct.
Si Lure: Date:
Phone#: sOt —3 7-572....6)
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 30City/Town Clerk 4.0 Electrical Inspector 50Plumbing
inspector 60Other
Contact Person: Phone#:
THE COMMONWEALTH OF MASSACHUSETTS
Office of Consumer Affairs & Business Regulation
HOME IMPROVEMENT CONTRACTOR
TYPE:Individual
Registration Expiration
180664 12/10/2026
CHARLES SIMMONS
CHARLES E. SIMMONS
156 WITCHWOOD RD
SOUTH YARMOUTH, MA 02664
Undersecretary
Commonwealth of Massachusetts
Division of Occupational Licensure
Board of Building Regulations and Standards
.. . ...... ...........
CS-080901 kr •ires: 01/25/2026
CHARLES E IMMONS
156 WITCHVI( OD RD
SOUTH YARMUTH MA 02664fic
& O
Commissioner ceL