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Home My WebLink AboutBLDX-25-1146 application /fog yA'l; �a R E C E 1 F- E D Office Use Only tea' Permit# Nii-ark—kls-k � ' SEP 0 2 2025 Amount -M AWRtit• 'cORPORME°„A0// BUILDING DEPARTMENT `. u ny -..._._. __.. ...) EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: ?8 'ii( U jp"7-Acvp( , L.Ize. S Aititiol --- OWN ER7reng.36 NAMEMIQtSLA\ LLO M.PP EZ+ ),DRE.S.S Avia_ 4)3 TE53 7 3 33Z— CONI'RACTO : GAL�Jyf l a1�7•y� �"u�}Ilt 1i.4 —_�U , JIP7 -57 NAME T MAILINt,,ADDRESS s . if 14,0_11 v u— TEL.,t EMAIL014�J�.f L SLoU S c NST�J L'T7DC,/ Ca GI mIA,i& ' C 1 Ocsidential 0 Commercial :,first.Cost of Construction$ 1 CESO 0 Homeowner is Applicant? Yes No Home improvement Contractor Lic.# l 6-16¢ Construction Supervisor Lie.#(25— CD 6 I WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate required) Wood Stove Siding: #of Squares 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 I s/1V Location of Facility I declare under penalties of pe. th he statements herein coot: ed are true and correct to the best of my knowledge and belief. 1 understand that any false answer(s) will be just cause for denia r r tion of my lice and f secution and .G.L.Ch.268,Section I. Applicant's Signature: Date: 1 — Z — ZO z.s Owners Signature(or attachment) Date: Z — `z-o 24.— Approved By: Date: Building Official(or designee) Rev 6/24 Commonwealth of Massachusetts Division of Occupational Licensure Board of Building Regulations and Standards e„er�,s a,p4CTI .41?-r CS-080901 xtv *ires: 01/25/2026 CHARLES E IMMONS 156 WITCH OD RD SOUTH YAR(t)UTH MA 02664 Commissionerb/ :., 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 The Commonwealth of Massachusetts Department of Industrial Accidents 9 _ — Office of Investigations (; Lafayette City Center — 2 Avenue de Lafayette,Boston,MA 02111-1750 www.mass.govldia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individualr Address: /s6 i c/l•rc 4-1 I,C/O a n - City/State/Zip S OZ/e1,4 Phone#: Are you an employer' heck the appropriate box: 4. 1 am a general contractor and I Type of project(action d): 1.❑I am a employer with ❑ r employees� (full and/or part-time).* have hired the sub-contractors 6. New❑ construction 2.t]a t tun a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition workingfor me in anycapacity. employees and have workers' caP Y 9. ❑Building addition [No workers'comp.insurance comp.insurance.: required.] 5.❑We are a corporation and its 10.❑Electrical repairs or additions 3.❑1 am a homeowner doing all work officers have exercised their 1 l.❑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.�'Olher�by 1ItPL�� comp.insurance required.] 'Any applicant that checks box#1 must also till 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 ant an employer that is providing workers'compensation insurance for my employees. Below is the policy and job cite information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: Z 1 f./1 y.11=YTAti ( '(t t City/State/Zi$ 1 ? R,, 07414 Attach a copy of the workers'compensation policy declaration page(showing the policy nu ber 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 the D or' surance coverage verification. I do hereby certify nd to pains an enalfies perjury that the information provided above is true and correct.de Signature: Date: J —7--Z67.� 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): 1111Board of Health 20 Building Department 30City/Town Clerk 4.0 Electrical Inspector 5Elumbing Inspector 6.00ther Contact Person: Phone#: