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Home My WebLink AboutBLDX-26-1123 application 01 y RECEIVED Office Use Only r � 7(y C ] ? Permit# r '\ O x + ' SEP 2 1 2026 8 Amount yCoAPORA(ED`y3./ BU DING D f\f-� _ By EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 12-14 Rosetta Street West Yarmouth OWNER: South Yarmouth Serires LLC. 137 Harbor Bluffs Hyannis MA 508-280-6025 NAME PRESENT ADDRESS TEL. # CONTRACTOR: Project Managers CC. LLC. 15 Lexington Lane Yarmouthport 508-246-1476 NAME MAILING ADDRESS TEL.# EMAIL: Fairwaywilly@comcast.net /❑Residential 0 Commercial C'Est.Cost of Construction$ 18,500.00208829 Homeowner is Applicant? Yes No Home Improvement Contractor Lic.#208829 Construction Supervisor Lic.#CS-095981 WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate required) Wood Stove Siding: #of Squares 13 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 Yarmouth Landfill *The debris will be disposed of at: Location of Facility I declare under penalties of perjury that the stat: en• •rein contained . e and correct to the best of my knowledge and belief. I understand that any false answer(s) will be just cause for denial or rev ti n o my i • d for prosec lion un.er M.G.L.Ch.268,Section 1. , Applicant's Signature: 1 Date: q, I .4l I ✓�� Owners Signature(or attachme Date: ApprovedDate: / -goic By: Bu mg icial(or designee) Rev 6/24 +t: The Commonwealth of Massachusetts ;�:_ ------= Department of Industrial Accidents `,-,1 �-y ' 1't /4i_, ,, ,. Office ofInvestigations t= _:, � - ir Lafayette City Center \. ,. ��=ylam.___..._. •.ly� ---.i 1:-: 2 Avenue de Lafayette, Boston, MA 02111-1750 "' °{- r www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Project Managers CC. LLC. Address: 15 Lexington Lane City/State/Zip: Yarmouthport, MA 02675 Phone #: 508-246-1476 Are you an employer? Check the appropriate box: Type of project (required): 1 . Li I am a employer with 4. J I am a general contractor and I 6 [] New construction employees (full and/or parttime).* have hired the sub-contractors 2. ❑ I am a sole proprietorpartner- listed on the attached sheet. 7. ❑ Remodeling or ship and have no employees These sub-contractors have 8. LI Demolition working for me in any capacity. employees and have workers' 9 Building addition [No workers' comp. insurance comp. insurance. required.] 5. 0 We are a corporation and its 10.❑ Electrical repairs or additions 3. LI I am a homeowner doing all work officers have exercised their 11 .E1 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 Trim & Sidewall employees. CN o workers 13.❑ Other comp. insurance required.] *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: Travelers 6 H U B-1 K86160-0-27 Expiration Date: 2-25-27 Policy # or Self-ins. Lic. #: p Job Site Address: 12-14 Rosetta City/State/Zip: Yarmouth copyof the workers' compensation policy declaration page (showing the policy number and expiration date). Attach a P Failure to secure, required as coverage a under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00one-year and/or imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine P against up to $250.00 a day a ainst 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 and' the , # •ns , 1 penalties o per] ry that the information provided above is true and correct. . Date: ` / ,t0 re: _ `� Signature: vi - c____ y Phone #: �Z�, G - / `( 76 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): 1❑Board of Health 20 Building DepartmenttY 3DCi (Town Clerk 4.❑ Electrical Inspector 50Plumbing Inspector 61:Other Phone #: Contact Person: