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Home My WebLink AboutBLDX-25-1582 Oie Ya9� Office Usc Only 0�. Permit# a_ ,o�- y DEC 2 2025 Amount 4sc 6-7) ooRAteo C 33 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 104 Pawkannawkut Drive, S. Yarmouth, MA 02664 OWNER: 1 Look Solutions 76 Vandermint Ln., Hyannis, MA 02601 774-521-7885 NAME PRESENT ADDRESS TEL. # CONTRACTOR: Samuel Naoom 76 Vandermint Ln., Hyannis, MA 02601 774-521-7885 NAME MAILING ADDRESS TEL.# EMAIL: sandsconstruction@comcast.net X]Residential ❑Commercial I Est.Cost of Construction$25,000.00 Homeowner is Applicant? Yes No Home Improvement Contractor Lic.# 147624 Construction Supervisor Lic.#CS-096833 WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate required) Wood Stove Siding: #of Squares 10 Replacement windows:#20 — Replacement doors: #4 Roofing: #of Squares 10 Insulation Temporary Ho me q p yMobile 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: Yarmouth Town Waste Facility 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 denial or revocation of my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: t Date: 1 2/1/2025 Owners Signature(or attachme\\\\nt"``))) Date: Approved By: Date: Building Official(or designee) Rev 6/24 Commonwealth of Massachusetts • Division of Occupational Licensure Board of Building Regulations and Standards Constry fS ervise CS-096833 1,pires: 11/10/2024 SAMUEL F N LOOM 76 VANDERMINT LN HYANNIS MAYf)2601 Commissioner ) � YFv"c14a Office of�onsumeA sdQ�tdC�'fttion • HOME IMPROVEMENT CONTRACTOR -14 TYPE:Individual Rgi__� ►&ti�n 07/24/2023 147624 SAM NAOOM SAMUEL F.NAOOMa06i ° 76 VANDERMINT LN. HYANNIS,MA 02601 Undersecretary ... The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations l Lafayette City Center 02) (;� 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):Samuel Naoom Address:76 Vandermint Lane City/State/Zip:Hyannis, MA 02601 Phone #:774-521\7885 Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ 1 am a general contractor and 1 employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2. 1 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 n' 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 11.0 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 RoofinglSiding/Windows1Doors employees. [No workers' 13.m Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 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:N/A Policy#or Self-ins. Lic. #:N/A Expiration Date:N/A Job Site Address: 104 Pawkunnawkut Drive City/State/Zip:S. Yarmouth, 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 $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 certifyunder the pains and penalties of perjury that the information provided above is true and correct Signature: t _- \ Date: 12/1/2025 Phone#: 774-521-7885 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 5E'lumbing Inspector 6.0Other Contact Person: Phone#: