The URL can be used to link to this page

Home My WebLink AboutBLDX-26-603 application of YVi RECEiVED1 Office Use Only Q Permit# $LOX—ak,{oO} 3 R. jJUN1226 Amount t h`OAPORATO BUILDING L:,_r ARTM1=Nt EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: v��-o�r ( Bt rt�n IAA . U.Vtirc - c ?o r-k-1 IV ,Pc 02(0 -S OWNER: (2.0De1 g5 9-,002440.Ec \G. NAME / ,� PRESENT ADDRESS TEL. # CONTRACTOR: FEE AL (Wr . Corp,v0 251 CokuUcfi P.d.Massnpu, (AA .*,i3 • 21 4-9. NAME MAILING ADDRESS TEL.# EMAIL:bm Gacpu IO c q(V\DL-b C OrA / acAl aneeComc�t red °(�� bb Q Residential ❑Commercial ❑ Est.Cost of Construction$ Homeowner is Applicant? Yes ✓ No Ilome ImproNemcnt Contractor Lie.# Construction Supervisor Lie.# WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate required) Wood Stove Siding: #of Squares Replacement windows:# I 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: 6 D n L lat c VA-c\t; A\SPO5^'► 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 I. " Applicant's Signature: ` ( Z tU Date: [I 12O2-6 Owners Signature(or attachment) FAA Date: Ip '(I 12021, Approved By: Date: Building Official(or designee) Rev 6/24 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 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):Blue Mountain Carpentry LLC Address:251 Cotuit Rd City/State/Zip:Mashpee MA 02649 Phone#: 774-368-2647 Are you an employer?Check the appropriate box: contractor and l Type of project(required): 1.❑ 4.Iamaemployerwith ❑I am a general employees(full and/or part-time).* have hired the sub-contractors 6. New construction listed on the attached sheet. 7. ❑Remodeling 2.® I am a sole proprietor or partner- 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.❑ 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.]' c.152,§1(4),and we have no employees.[No workers' I3.®Other Siding-Replace siding comp.insurance required.] on front of house *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 pro,ide 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 penaldes of perjury that the information provided above is true and correct. Signature:Isaias Reis Date:06/09/2026 Phone#: 774-368-2647 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 2❑Building Department 30City/Town Clerk 4.0 Electrical Inspector 50Plumbing Inspector 6.DOther Contact Person: Phone#: Home Improvement Contractor Registration Card Registration valid for use type, only before the expiration date. Type: Limited Liability Company (LLC) ` r( Y Number: 207339 Expiration: 06/08/2028 Issued to: • Blue Mountain Carpentry LLC Isaias Reis 251 Cotuit Rd Mashpee, MA 02649 ito, Office of Consumer Affairs& Business Regulation Ldyl`d`R. D'Emilia 1 Federal St.,Suite 0720, Boston, MA 02110-2012 Undersecretary