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Home My WebLink AboutBLDX-25-1498 applicaiton ,01 yA Office Use Only ' o P ��5' /y 7 Amount •'YPORAt EDi EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 413" IP &th1 . cJ'aJyLp (.L . ico,,,,,,„., J ' OWNER: LL (1 Nam- �g - _ W.I NAME PRESENT ADDRESS T L. # f/`—ti 7 R ag7q CONTRACTOR: NAME jj n/ MAILING ADDRESS TEL.# ld EMAIL: red, t $DAIS c n tj/- .. ezni esidential ❑Commercial Est.Cost of Construction S l ' Homeowner is Applicant? Yes ✓ No Home Improvement Contractor Lic Construction Supervisor Lic.# 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 * lease su it utility disconnect letters for electric& gas-structures over 75 years old require historical review *The debris will be disposed of at: C�2 /D L ation of Facility I declare under penalties of pe ' that the stateme rein 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 evocation of my li ns and for p ecution under M.G.L.Ch.268,Section I.plicant's Signature: ..4H—C.A.1, Date: /!/✓ 7_ 2v�( ( -5 Owners Signature(or attachment) Date: Approved By: Date: Building Official(or designee) Rev 6/24 The Commonwealth of Massachusetts JDepartment of Industrial Accidents Ofce 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 'DU H1'Z/2-7/ Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ 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. New construction 2.❑ I am 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' P 9. ❑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.❑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 kaor` 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. tContractors 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 certi under the pains and penalties of peijury that the information provided above is true and correct. //v Signature: n�/ 1j" V,Ctki y' Date: /��— '��i�s5 Phone#: 1bl -1dL- A 7' 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): lDBoard of Health 2❑Building Department 31:City/Town Clerk 4.0 Electrical Inspector 5EI'lumbing Inspector 6.1:1Other Contact Person: Phone#: . , . t-sr- ',.,4„7„): fe I, .,.....") Ira GB ei REGISTRY OF MOTOR VEHICLES Receipt Date: 11/07/2025 Receipt #: L0680448304 Transaction Location: Hyannis/Yarmouth Merchant ID: 000025949479 Terminal ID: 012 Application ID: ATLAS / Verifone PointSCA Transaction(s): Reference Number Debt Type Fee/Tax Penalty Interest Total* Amount Paid Balance Due S****0640 License Issuance 25.00 0.00 0.00 25.00 25.00 0.00 * Note: The amount under the "Total" column reflects the original debt owed. Payment(s): Payment Type Check Number Payment Amount Credit/Debit Card N/A 25.00 Credit/Debit Card Payment Information: Invoice Account Cardholder Authorization Approved Amount Card Entry Mode CVV AVS ME0580 MC 9763 CALOGGERO/ROBERT 780770 $25.00 Chip Read Conditions of Sale: If a balance remains due, you may access your account through Mass.Gov/RMV to make a payment online. If the payment is returned due to insufficient funds, a fee of $15.00 will be applied to your account. All sales are final. Massachusetts Registry of Motor Vehicles l P.O. Box 55889, Boston, MA 02205-5889 1 mass.gov/rmv Page 1 of 1