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HomeMy WebLinkAboutBLDX-25-1618 Y,,- E. Office Use Only r I 1 Permit#BLt7 --lleN 1E0\ 41 DEC 10 2025 j t 0 F y Amount l a- y R,' BIJI1_DG L- ,>k 1 N.1-NT By 1 ORA1E� IN EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 38 Captian Small OWNER: Mill Creek LLC / Dean Shores NAME PRESENT ADDRESS TEL. CONTRACTOR: David Dadmun 43 Pond Street West Dennis MA 508-367-5851 NAME MAILING ADDRESS TEL.# EMAIL: david.dadmun@gmail.com )Q7 Residential 0 Commercial ❑ Est.Cost of Construction$$45,000.00 Homeowner is Applicant? Yes No X Home Improvement Contractor Lic.# 128718 Construction Supervisor Lic.#074205 WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate required) Wood Stove Siding: #of Squares 15 Replacement windows:# 12 Replacement doors: # Rooting: #of Squares 7 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: S&J Exco Dennis MA 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 ford ' revocati o m ' ense and for prosecution under M.G.L.Ch.268,Section 1. / Applicant's Signature: "� �' Date: / " )�` Owners Signature(or attachment) Date: i i 2d/ 1 i Approved By: Date: Building Official(or designee) Rev 6/24 The Commonwealth of Massachusetts a., Department of Industrial Accidents �� Office of Investigations 1,1 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 Letibly Name (Business/Organization/Individual): David Dadmun Address:43 Pond Street City/State/Zip:West Dennis MA 02670 Phone#: 508-367-5851 Are you an employer? Check the appropriate box: Type of project(required): 1.ID I am a employer with 2 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 tY 9. ❑ Building addition [No workers' comp. insurance comp. insurance.. 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 12.0 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 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: IFPS Policy#or Self-ins. Lic. #:NYT-57389 Expiration Date: 7-22-2026 Job Site Address: 38 Captian Small South Yarmouth City/State/Zip: MA 02664 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 S1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 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 hereb. ertiy unde aims and penalties of pedury that the information provided abov is true and correct. Signature ��� Date: /! �� 4,'.) - - Phone#: 5 6, 1 — `-57. >1 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): 1OBoard of Health 20 Building Department 3ElCity/Town Clerk 4D Electrical Inspector 5DPlumbing Inspector 6.0Other Contact Person: Phone#: