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HomeMy WebLinkAboutBLDX-25-1330 r O4;Yw ,,j 5,�Q 15 Office Use Only. �. " :p�.., Pennita 16 H i \msmm 2t 47 •9/9,?b 070 eV OCT 0 2 2025 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 ^� /� (508)398-2231 Ext. 1261 CONSTRUCTION ADDRESS: . 2_7 1r���'sQ c,+ YY1 O2,(7 „ - -. OWNER. L17-441.sA gSp 2_22. _ 1 Sd.�a' (�1-.l. S ]�o�O ) NAM PIO-SFV\\DDI)RI SS TEL. CONTRACTOR: 'r 9,1 ii-,,t -c (/31A1oe-©,-e_ we,.a: "e-ar* 523Kid80 2-14 "- \:\\1 F. \IIll \G.\DDRI-SS azfo? TEL EMAIL:14YL47'1 YY f-.• Cd L-C.Maa..\ 4_(a.-(W Or—A _Residential )ercial Est.Cost of Construction S esa--_____ Homeowner is Applicant? A rs Home Improsement Contractor Tic.# g Construction Supersisor Lic.# LS 'r for2.7 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 •Please submit utility disconnect letters for electric&gas-structures over 75 rears old require historical reslew 'The debris will he disposed of at: r►f "j.GYI"1".2.1, -?"I �k\. - _---.- Location of Far I I V_1 I declare under penalties of perjury that the statements herein contained are true and correct to the hest of my knooiedge and belief: I understand that any tale answensl will be just came lin denial or rceocalion of my license and for prosecution under SIC;.L.Ch.'_fig.Section I. /,�/,s/+ .Applicant's Signature Date. I d-] a/��s(.4. Owners Signature(or attachment)/��,,�� Date: (/413 G7/ 2� :\pprosed Hy-. n)rlr'll✓i-0\ ,pr 11 C`��i9 Date- _. f / Budding Official for designee I Res 6 24 The Commonwealth of Massachusetts Department of Industrial Accidents 5 1_ Office of Investigations Lafayette City Center =Z11,7 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): 1 1,1 r.,„ Address: 1/ 15071,t..r .r)L e W 16 2—e7 City/State/Zip: Phone #:_ "LL;� Are you an employer? Check the appropriate box: Type of project(required): t4 n a employer with_1 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 working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.: 9. El Building addition 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 YP 12.0 Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other comp. insurance required.] Pc. . 64� '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: Rig ��ri•iy Policy#or Self-ins. Lic. #: Cc- 4'G 0 " c 6 Z ) 2024 Expiration Date: 17_/ l 7;5 Job Site Address: 2:2-7 1) r y r City/State/Zip:ioiti,,A,r• -n10&LE 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 under the pains and penalties of peijury that the information provided above is true and correct. Si ature: = Date: )6//2,2,S Phone#: G)cz ( 0 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 40 Electrical Inspector 50Plumbing Inspector 6.0Other Contact Person: Phone#: { .„ , ; /4 AI --7-7/71-6 t,-- ..,/ C r ., 6,2,71 0 Nic c cc.2 c-__,- m,9,,-e _ co/Li . ._, . . _ , _., .. _ ___ ,_ , - - . __ „ . ,- - - -ssenost commeTION NZHVICNS - ,-' ' , 5,1 Constretien Supervisor License (CSL) L5 Et ' i27 II 1 _ —OR.. ) 5 e, l I T 14C.elvyiNk,n__ License Number Expiration Date Name of CSA,{older ) List CSL Type(see below) L. 1 ( � " 1GI11 �f" - N8:I§il€i _ ti011 /3 � - — civ- ' in A 0 t� �nr�sirici®d (l�uildih�s� �1a J8,666 cii, ft)�j � Ica 3 R Restricted 1 ik2 Family Dwelling City/Town, State, ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Humus Appliances �� 5 .3 h kl-ic_cvr,c4,5€69e, i Insulation Telephone Email address 3 s1,,1 4,141 I) Demolition 5 C..e2 Registered Home Improvement Contractor (HIC) ,DJ UCiv 1 S,.� Iii% r . 9i 11 " k)1 VvtA 'l''vI,r CK.'Yf�✓\ HIC(Registration Number 4h0nnate Company Name or HIC Registrant Name t7 11/Y ----- - m Gr t'N,--..to leis G �+ t ,., ii: In ,tfe Emil ittidf� t � �° 0 7i 7,3 - 2 () �S' City/Town, State, ZIP Telephone TON .WO RS EN NINS INN E AFFIDAVIT l e. 1524 �O Workers Compensation Insurance affidavit must be completed and submitted with this applications Failure to provide this affidavit will result in the denial of th Issuance of the building permits Signed Affidavit Attached? Yes No . 0 SEellG 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNE, 'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I; ag CIWIlef of ille gtitlept p etc Witty 4i1thFi,4f r. l8 aet on illy behalf; ill d1 tips t€1a1MMM to wofk dli hefiied by this building efiiiii a Iiedti8H: 1. . i V( /-)-6-- Print er's Name (Electronic S` a Date fRD AGES DECLARATION ' By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information contained in t is application is true and accurate to the best of my knowledge and understanding. not wner's or Atit ortze A ent's 1 awe ectrontc I nature $a'-' ' -''''''s - ' - -148ffl: - . - ' - - 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 o heatings stem - umber offg,4 decks!pore es — ___________ , e o lea in s TS eir. i I; --- - 1. 44Tillfil PitliFEt §R144fP f8s4gP. 4Y 13g §Ittl§tit140 fir I 1 Pf*Et 8§1';