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HomeMy WebLinkAboutBLDX-26-25- RECEIVED ---- Office Use Only 0� Yq�� Permit# �o`t6 a5 `14 o A JAN 15 2026 /+C°RPO RATED���, BY. ��11 vv Amount EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 (508)398-2231 Ext. 1261 CONSTRUCTION ADDRESS: (e 3„5— /c!!/to fr? Ql&0 G / t44 4 d 5( C M -Z-K f/2-©Per-7 ec LLC } c OWNER: R��/VteIie �oir.,�c 63 L,# L&1 t one £ 6R <<i� iP'--y9 -s f 'NAME PRESENT ADDRESS TEL. # 75eiowyo 01-5-act A7 GLc LoU (4ke IA4-aa3(.a CONTRACTOR: i.e5o(S. 2:2 1Are fy0 0ke hem ,-s �16! (Z & 4 ' -- —Y.g pe5 NAME MAILING ADDRESS ` TEL.# EMAIL: L 7 -t )jJi4 Ay O %Z GAlQ!Lot C /1 esidential 0 Commercial B'Est.Cost of Construction$ p 'd? Homeowner is Applicant? Yes No x Home Improvement Contractor Lic.# l! 17 Construction Supervisor Lic.# CS^e:>p7.c 91l WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate required) Wood Stove Siding: #of Squares (` � S Replacement windows:# Replacement doors: # P 5l Se,eh 7 211 , 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 c /AI *The debris will be disposed of at: ' `De. v t S A 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 revoc Lion of my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature filk Date: L //31 V d RC. Owners Signature(or attachment) Date: Approved By: Date: Building Official(or designee) Rev 6/24 The Commonwealth of Massachusetts Department of Industrial Accidents t' Office of Investigations i` 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):.Det , Ay0 2 .�s `o cs £L C_ n L.0 v,s F'c -Deft)t9), Address: 'fQ h(tic /-iilt ti onit r L3X0 P5,r1c c.'rz IM 1•4- tz)a� c City/State/Zip: viiko oZin Phone#: ' "�— (—5'�� 2.6 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. El 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 working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.: required.] 5. g 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.❑ Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.QrOther5dtA.,(7 comp. insurance required.] la-)c I e� *My 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: _ 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 certify u der the pains and penalties of perjury that the information provided above is true and correct. Signature: L G� -- Date: I /43/zc'c6' 2"' � Phone#: Pi 7 9 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): 10Board of Health 20 Building Department 3❑City/Town Clerk 4.❑Electrical Inspector 5alumbing Inspector 6.0Other Contact Person: Phone#: L. w SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License (CSL) License Number Expiration Date Name of CSL Holder List CSL Type (see below) No. and Street Type Description U Unrestricted (Buildings up to 35,000 cu. ft.) R Restricted l&2 Family Dwelling City/Town, State, ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor (H IC) HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name No. and Street Email address City/Town, State, ZIP Telephone SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152. § 25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuance of the building permit. Signed Affidavit Attached? Yes ... ... ... . ❑ No ... ... ... .. ❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT ! I, as Owner of the subject property, hereby authorize D L' .AA 10 A 1" ASo C.t' 7'�s L L C c L of is f to act on my behalf, in all matters relative to work authorized by this building permit application. /<Ce ‘2y1 r :Ar Print s Name (Electronic nature) ate SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. Print Owner's or Authorized Agent's Name (Electronic Signature) Date NOTES: 1 . An Owner who obtains a building permit to do his/her own work, or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor (HIC) Program), will not have access to the arbitration program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program can be found at www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps 2. When substantial work is planned, provide the information below: Total floor area (sq. ft.) (including garage, finished basement/attics, decks or porch) Gross living area (sq. ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/ porches Type of cooling system Enclosed Open 3. "Total Project Square Footage" may be substituted for "Total Project Cost" .... Commonwealth of Massachusetts vt, Division of Occupational Licensure Board of Building Regitpations and Standards Constrjetiltari' ISlipervisor ...., .^ ..f CS-097691 s • EI,):iires: 07104/2025 LOUTS F DE4AY0 40 PINE HILLS DRIVE UNIT#1326 to PLYMOUTH M1),..02360'- ''..- Commissioner . , Home(/s/) Contractor Log In Vs/contractor-login) Contractor Search Tool(/s/hic-contractor-search) Submit Complaint(/s/submit-a-complaint) Submit Guaranty Fund Claim(/s/submit-a-guaranty-1 An official website of the Commonwealth of Massachusetts Here's how you know Search Contractor Registration and History *indicates required field Always confirm that a contractor is registered before you hire one.Should you need assistance in the future,you will not be eligible for arbitration or the Guaranty Fund if the contractor you hire is not registered. Contractor Account Name DEMAYO AND ASSOCIATES LLC Business Email Address Phone Number I.demayo42@gmail.com 6172124690 HIC Registration Number Registration Effective Date 194524 January 13,2026 Registration Status Registration Expiration Date Active January 13,2028 Physical Address Mailing Address 40 Pine Hills Drive 40 Pine Hills Drive Unit 1326 Unit 1326 Plymouth,MA 02360 Plymouth,MA02360 US US Responsible Person 1 of 1 item Name v Contact Email Louis F DEMAYO Idemayo2002@yahoo.com(mailto:Idemayo2002@yahoo.cortt) Previous New Search Office of Consumer Affairs and Business enterprise Information Technology Accessibility Policy(https://www.mass.gy-advisory/enterprr f ion-t hno o - - y*toolicy-stateMent?). k r. Regulation I Home Improvement Contractor Program Need help?Call our Consumer Hotline at 617-973-8787 or 888-283-3757(toll-free) Monday-Friday,9 a.m.-4:30 p.m. vfe 1 Federal Street,Suite 0720,Boston,MA 02110-2012