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Home My WebLink AboutBLDX-25-1277 E O� VA 4 ® C a Office Usc Only,'�A ` �..____._.—..—. Permit# Cif I k�- �/ SEP 252025 Amount C 4 By:cp-....-Loti.3 - EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTII Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 59 Williams Rd West Yarmouth OWNER: Whittemore Enterprises Inc 20 Rogers Rd Harwich Ma 774-268-9682 NAME PRESENT ADDRESS TEL. # CONTRACTOR: Jeff Whittemore 20 Rogers Rd Harwich Ma 774-268-9682 NAME MAILING ADDRESS TEL.# EMAIL: whittemoreenterprisesinc@gmai(.com )O Residential ommercial I Est.Cost of Construction$3000 Homeowner is Applicant? Yes V No Home Improvement Contractor Lie.#1 65058 Construction Supervisor Lie.#1 030 1 9 WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate required) Wood Stove (Siding: #of Squares ( Replacement windows:# ' I Replacement doors: # I : S D / /1 � 1'7 ('Roofing: #of Squares 5'5 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: Barrows Dumpster service Location of Facility I declare under penalties of pc i,ry t ents 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 -vo atio of licen d for prosecution under M.G.L.Ch.268,Section I. (� Applicant's Signature: i/ Date: /-v -2.0 t 5- Owners Signature(or;/ .,ent) Date: Approved By: Date: Building Official(or designee) Rev 6/24 The Commonwealth of Massachusetts Department of Industrial Accidents '` Office of Investigations - Lafayette City Center 2Avenue 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):Whittemore Enterprises Inc Address:20 Rogers Rd City/State/Zip:Harwich,Ma 02645 Phone#:774-268 9682 Are you an employer?Check the appropriate box: Type of project(required). 1.❑■ I am a employer with 2 4. ❑l am a general contractor and I employees(full and/or part-time).' have hired the sub-contractors 6. ❑New construction listed on the attached sheet 7. 0 Remodeling 2.❑1 am a sole proprietor or partner- ship and have no employees These sub contractors have 8. 0 Demolition working for me in any capacity. employees and have workers' [No workers'comp.insurance comp.insurance.# 9. ❑Building addition required.] 5.0 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 12111 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 ail 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 subcontractors 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:Rogers and Gray Policy#or Self-ins.Lic.#:WCC-500-502-2632-2026 Expiration Date:7-15-2026 Job Site Address:59 Williams Rd City/State/zip:West Yarmouth,Ma 026' 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 Signature: Date: Phone#: 774-268-9682 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): 11:1Board of Health 20 Building Department 3❑City/Town Clerk 4.0 Electrical Inspector 50Plumbing Inspector 60Other Contact Person: Phone#: • IT Commonwealth of Massachusetts Construction Supervisor Division of Occupational Licensure Unrestricted-Buildings of any use group which contain less than Board of Building R gulations and Standards 35,000 cubic feet(991 cubic meters)of enclosed space. r ,,0.4ACHtJSF'.. 4` rs CS-10301S z` Spires: 12/0312026 JEFFREY D VjfHITTEMORE .--- 20 ROGERS D HARWICH MC 02645 i.:.4qt , O y, F,' C �OLl.Vd(103 . -i Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. Commissioner C Et / sue, Contact OPSI:(617)727-3200 or visit www.mass.gov/dpl/opsi THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation Registration valid for individual use only before the HOME IMPROVEMENT CONTRACTOR expiration date. If found return to: TYPE:Individual Office of Consumer Affairs and Business Regulation Registration Expiration 1000 Washington Street -Suite 710 165058 12/16/2025 Boston,MA 02118 JEFFREY WHITTEMORE 7 i. JEFFREY WHITTEMORE 20 ROGERS RD HARWICH, MA 02645 Undersecretary Ot alid without signature iv