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Home My WebLink AboutBLDX-25-1470- g. ,l pg Yq R E C E ��f L., cOfficeUssee Only tit � p'.. 4 Permit# /` d-5-1 —b C y OC Amount i 4 ,tea....._ '' *PORAt�`%' BUILDING DEPARTMENT EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1 146 Route 28 South Yarmouth, MA 02664 q /n�II (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: e.w \e A a L1n OWNER: f / J /\,.-)JA /LJe-rr.n-) /.)A-) q*-'/VCr,.s Y:c.1- ),A pD00 --2 ) — 4/2 NAME / PRESENT ADDRESS TEL. # CONTRACTOR: -=—'Mvt. L- �A„. AN,t» 4,3 ` o Nc S 1 }.1 i ?;S 4 d S--3.et :.-5— J / NAME MAILING ADDRESS TEL.# EMAIL: a A v el 4 A 1 - J a 6 6 Ff;. 1 . C_ es iv-, esidential Commercial Est.Cost of Construction$ 1/4 Oda^ c. a J Homeowner is Applicant? Yes No Home Improvement Contractor Lie.# / 7 / 6 Construction Supervisor Lic.# � 7 `71•Q C 4 WORK TO BE PERFORMED Tent Duration // (Fire Retardant Certificate required) Wood Stove Siding: #of Squares I(� Replacement windows: # Replacement doors: # / Roofing: #of Squares c 3 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: i I-- r` t d ejr/-/ �". L 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 de ' o titSif3ti license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: f0 123j 4— Owners Signature(or attachment) W ' 727-M7 V"� 1 Date: 3l G� 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): _ p w.v Address: e/ 3 o..3 S 1 City/State/Zip: I✓'D---N N-sr pi A Phone#: a 2— Are employer?Check the appropriate box: 4. I am a general contractor and I Type of project(required): 1 am a employer with � ❑ employees(full and/or part-time).* have hired the sub-contractors 6. New construction listed on the attached sheet. 7. ❑Remodeling 2.❑ I am a sole proprietor or partner- ship and have no employees These sub-contractors have 8. Demolition workingfor me in anycapacity. employees and have workers' P tY• 9. ❑Building addition [No workers'comp.insurance comp.insurance.: required.] 5.❑We are a corporation and its 10.11 Electrical repairs or additions officers have exercised their MO Plumbing repairs or additions 3.El I am a homeowner doing all work myself.[No workers'comp. right of exemption per MGL 12.❑Roof r pairs insurance required.]t c.152,§1(4),and we have no employees.[No workers' 13.0 Other co i comp.insurance required.] *Any applicant that checks box Ill must also fill out the section below showing their workers'compensation policy informati n. 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: )) I Policy#or Self-ins.Lic.#: til/i S3 77 9 Expiration Date: 7/ (f)L Job Site Address:_9 New r ;ti I Z A e_ City/State/Zip: A> tti v 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided a ove')true and correct. Si -- Date: X.3 I 2.}— Phone#: o 7 b Official use only. Do not write in this area,to be completed by city or town official. City or Town:_ Permit/License# Issuing Authority(check one): 11=1Board of Health 20 Building Department 30Ctty/Town Clerk 4.0 Electrical Inspector 50Plumbing Inspector 6.00ther Contact Person: Phone#: Commonwealth of Massachusetts Division of Occupational Licensure Construction Supervisor 1 & 2 Family Br 1rd of Building Reviations and Standards • ...-.1ACHCLik_,, „ ,t_ 0, .,, SFA-074205 44;' VA pires: 12/31/2026 DAVID L. DACOIUN ,-- 43 POND STKEET WEST DENNit MA 02670 '..... .:$: .. 1 . .;:c- • 4()LLAMA'S) ..011111.11 Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. Commissioner \ ppL iy_ 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 RggLstratio_n Expiratipn 1000 Washington Street - Suite 710 128718 08/24/2025 Boston, MA 02118 DAVID DADMUN D/B/A D L. DADMUN CUSTOM BUILDERS ---- . .„--- _ ,-- DAVID L. DADMUN •,.,_______, Thi . .' 43 POND ST UNIT 7 f%-,"-, - ' ---------'- 4---------- e — k W. DENNIS, MA 02670 Undersecretary Not valid without signature • • -,,