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Home My WebLink AboutBLDX-26-416 application • --- RECEIVED Office Use Only ik T, 0 Permit#.ic'oatn-44/0 ' .,4 MAY 06 2026 Amount 1 Da$0"U O•. '� le M�TTACMCESE, / +c bA°% BUIIEfI'Pf�Tt ENT eY t 413O0t6-3 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1 146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: f g c.,- ,./il�b -'i y.4_44.4,r4_ OWNER: /l pi ./✓ 6 0/ N6 183 C,Ka/14e- _✓i. . Cj , 7— ‘'b -86 P 3 NAME PRESENT ADDRESS TEL. # CONTRACTOR: NAME / � MAILING ADDRESS TEL.# EMAIL: f 1 ,k /atil v' n�l.ce-c,e. co-AA. SResidential 0 Commercial Est.Cost of Construction S ' .2-61 t/ V Homeowner is Applicant? Yes, ` No Home Improvement Contractor Lic.# Construction Supervisor Lic.# WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate required) Wood Stove Siding: #of Squares J Replacement windows: # 4 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 D , 4k *The debris will be disposed of at: ` e'l' -Zt Z ` �ti�� i / Location orEility Cj V ` lj � 6✓J cc�. I declare under penalties of perjury that the statements herein contained are true and con'ect 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 I. -e and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: �' ' Date: •� (`" f�K XOwners Signature(or attachment) Date: Approved By: (.----- Date: Building Official(or designee) Rev 6/24 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations mx Lafayette City Center phis 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): X/ I .t C .I - 1 (7 _ Address: �u-� 6 _ City/State/Zip: vG( b 1 Phone#: 7 J 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. 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 3.[I 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 12.0 Roof repairs insurance required.]t c.152,§1(4),and we have no employees.[No workers' 13.®Other S-,c( , .Jr �.� comp.insurance required.] J *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. :Contactors 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 under the pains and penalties ofperjury that the information provided above is true and correct Signature: Date: S ,,S l C2 Phone#: i 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 31:City/Town Clerk 4.1:Electrical Inspector 50Plumbing Inspector 6.0Other Contact Person: Phone#: 5/6/26, 3:19 PM Image.In,g „,, g . r Z,,,-* .... , te, -,< f I ,, ,`m,t, 1 1.Pofil s`, `� +°� �`� REGISTRY OF MOTOR VEHICLES S vi 3. May 5, 2026 4:50 PM Confirmation Number: 0-857-853-840 Dear YIPING DING, Your address change request has been successfully submitted. Residential Address 185 CRANBERRY LN SOUTH YARMOUTH MA 02664-1008 Mailing Address SAME AS RESIDENTIAL ADDRESS Update Voter Address YES VOTER REGISTRATION: Your new address will be sent to the election official for your city and town to update your voter registration. If you were registered to vote at your previous address, your voter registration information will be updated. Contact your local election official if you do not receive mailed confirmation of your address change within 2-3 weeks. If you were not registered to vote at your previous address, this transaction will not register you to vote. To check your voter registration or register to vote, visit: https://www.VoteinMA.com. Thank you for choosing Mass.Gov/RMV as your Service Center of choice. Keep up to date with RMV updates by following us at X @MassRMV Massachusetts Registry of Motor Vehicles I P.O. Box 55889, Boston, MA 02205-5889 I mass.gov/rmv https://mail.google.com/riail/u/0/#inbox/FMfcgzQgLjSzZthKnfPQIMQhZVDHmgKp?projector=1&messagePartld=0.0 1/1 5/6/26,3:20 PM Image.png tt+�? Mass.gov MASS.GOV LOCATIONS REAL ID INFORMATION < Home Address Change Address/Contact Update Residential Address Get Reddy Address Line 1 Address Information 185 CRANBERRY LN Address Line 2 Unit Type Unit City State Zip SOUTH YARMOUTH MA-MASSACHUSETTS •• 02664-1008 Country USA Mailing Address Is your mailing address the same as your residential address? Yes No Update Motor Voter O Cancel < Previous Next > https://mail.google.com/mail/u/0/#inbox?projector-1 1/1