HomeMy WebLinkAboutBLDX-25-1602 �, �y`9 � Office Use Only
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IttiO\`� Permit# a Only
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0 t ..y Amount ��
z- DEC 0 8 2025
� M.TT4CML.A. 4
�CORPORAtEC�`A
EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28 1
South Yarmouth, MA 02664
2� (508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS: J �Ct4cr Ave ILL gk;w.a / A p Oa )?
OWNER: Pr,,tp„aa FtrAAAJ.eS (S4.0 pwA,r,,,..► AVC. L!-wt, jk4 Q24is- 77t1-J22-o$t7
NAMJL. PRESENT ADDRESS A, TEL. #
CONTRACTOR: At N heo r. 1 IVY ADDRESS L. Hy6,14.5 MP 1 olLta 7 7Y —�' —?yO�NAME
EMAIL: Se'hd4SCJAStfWI 0L.e,C0.A..cl.t kf#1 r
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Residential ❑Commercial Est.Cost of Construction$ 4 C./00
Homeowner is Applicant? \'es No______Home Improvement Contractor Lic.# 1 t/ 7 L ., 41 Construction Supervisor Lic.# LJ p 0 !c G1) :i
WORK TO BE PERFORMED
Tent Duration (Fire Retardant Certificate required) Wood Stove
Siding: #of Squares Replacement windows: # el 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: o cl t_..0
Locatiob 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 denial or revocation of my license and for prosecution under M.G.L.Ch.268,Section 1.
Applicant's Signature: (� . Date: El/8/) .,c
Owners Signature(or attachment) g Date: /1 ied
Approved By: _ Date:
Building Official(or designee)
Rev 6/24
The Commonwealth of Massachusetts
Department of Industrial Accidents
s., 1`: Office of Investigations
II`� ,1±1 Lafayette City Center
Vii:Fr 2 Avenue de Lafayette,Boston,MA 02111-1750
www.massgov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
c
Name(Business/Organization/Individual): aa. /U..ac.;ti
Address: 7(, IL-L..,,.:,..,1` L k.
City/State/Zip: 14,f,,,,tx rt() oft l3 Phone#: 7 7i-a1-"1 IPA;
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.R.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
working for me in any capacity. employees and have workers'
[No workers'comp.insurance comp.insurance.t 9. ❑Building addition
required.] 5.❑ We are a corporation and its 10.0 Electrical repairs or additions
eq ]
3.0 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.❑Roof repairs
insurance required.]t c.152,§1(4),and we have no
employees.[No workers' 13.111 Other jA,.,Jpa./0t1,, /,.,_,,9
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: 10 jp,
Policy#or Self-ins.Lic.#: N)A Expiration Date: O/A
Job Site Address:_3S na,..-Iv Avc- Peff X.—.-/. City/State/Zip:4J4r, ,,4A; (52 /,s'
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 u/�ier the pains and penalties of perjury that the information provided above is true and correct.
Signature: / Date: i -/2V f
Phone#: 7?Li - 5)i— 7 i S5-
Ofcial 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):
10Board of Health 20 Building Department 3❑City/Town Clerk 4.0 Electrical Inspector 50Plumbing
Inspector 6.0Other
Contact Person:_ Phone#:
. __
-4, .. __ .
$1-- - Commonwealth of Massachusetts
Division of Occupational Licensure ? /' '
Board of Building Regulations and Standards Offiice of ConsumeAf s'egliiiii #i jaition
"I HOME IMPROVEMENT CONTRACTOR Consto :Y n -:{�:ise.
,;�, %J' # TYPE: Individual
CS-096833 ` Registration Expiration
' ic�Dires: 11110/202 14 624 07/24/2023
SAMUEL F NA1OOM t SAM NAOOM
76 VANDERNiNT LN y '
Ai
HYANNIS MA"y2601
SAMUEL F. NAOOM
ti�� y 5 �t �,; 76 VANDERMENT LN, �.441.,`e'f.(a'Gl,`4
{I, d-‘` ; ' HYANNIS, MA •02601
L'' Undersecretary '1
Commissioner dty4G. K. 64-a /ra._
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