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Home My WebLink AboutBLD-23-003327 , kL -y f1 12i 1Uize 2.gb Office Use Only o1''Y4R 'C Permit# 31 1I 11 Amount(2g0.00 v rw, r s %),t,`,,,�„„,,r d 'Permit expires 180 days from issue date 0Lb -23 -6033Z-7 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department RECEIVED 1146 Route 28 E _ South Yarmouth,MA 02664 DEC 14 2022 (508)398-2231 Ext. 1261 CONSTRUCTION ADDRESS: � [_ 223 Route 6A, Yarmouth Port BUILDING DEPARTMENT uv ASSESSOR'S INFORMATION: Map: 122 Parcel:92 OWNER: Arpad Voros 223 Route 6A, Yarmouth Pc 508-280-5462 NAME PRESENT ADDRESS TEL. # CONTRACTOR: C. A. Vincent 17 Still Brook Road, Yarmoi 774-212-0938 NAME MAILING ADDRESS TEL.# ❑Residential El Commercial Est.Cost of Construction$1 1,000 Home Improvement Contractor Lic.#1 82000 Construction Supervisor Lie.#CS-095633 Workman's Compensation Insurance: (check one) 0 I am the homeowner El I am the sole proprietor 0 I have Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy# WORK TO BE PERFORMED Tent I I Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # RoofinExiig: #of Squares 18 (�)Remove existing*(max.2 layers) Insulation I I Old Kings Highway/Historic Dist. placing like for like Pool fencing I J Lk VI , Y I\xz - ►3) (-.(C- —OIL 441'''"t I 4 Pfi,..)_ 'The debris will be disposed of at: Chase & Merchant 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 vocation of my license and f secution under M.G.L.Ch.268,Section 1. Applicant's Signature: .../e/1./ Date: I 2-4 ;-2-. Owners Signature(or attachment) Date: //L Approved By: [ E Date: / `_ �/_� Building O (or gnee EMAIL AD SS: ;oiling District: Historical District: Yes -' No Flood Plain Zone: :- Yes No Water Resource Protection District: Within 100 ft.of Wetlands: Yes No _:. Yes No about:bla i. Problems caused by lack of Owner maintenance;problems caused by Owner abuse, misuse,modification,vandalism,or alteration;problems caused by Owners separate sub-contractors;and ordinary wear and tear. ii. Damages resulting from mold, fungus, and other organic pathogens are excluded from this warranty unless caused by the sole and active negligence of contractor as a direct result of a construction defect which caused sudden and significant amounts of water infiltration into a part of the structure. iii. Deviations that arise such as the minor cracking of concrete, stucco, and plaster; minor stress fractures in drywall due to the curing of lumber or warping and deflection of wood;shrinking/cracking of grouts and caulking;fading of paints and finishes exposed to sunlight. These are all typical (not material) defects in construction,and are strictly excluded from Contractor's warranty. iv. "Nuisance"tripping o`code required AFCI electrical breakers. In Witness Whereof,the parties have signed and sealed this Agreement in duplicate,each of which is deemed to be an original,on the day and year first above written. Crify;e:tv.47 7 fj 42, .4.--/Z (t. Christopher A.Vincent A a Ii6fos,Owner President,C A.Vincent Inc May 19,2021 :;-/ Date Date 17 STILL BROOK RD.,S.YAR,4OUTH.MA 026 4 I PH:(774)212-0938 FAX:(Sog)394-0550 I INFO®CAVNCLNT:CONI PAGE S 17oF7 7 of 7 5/19/21,2:28 P The Commonwealth of Massachusetts 1 =*=3 / Department of Industrial Accidents =A- 1 Congress Street,Suite 100 _�_ . Boston, MA 02114-2017 www.mass.aov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information //YY // Please Print Legibly Name (Business/Organization/Individual): (�, A- V I F/!'.ee. ` -) . Address: / 7 Si 7/ g 14- ieeeLL City/State/Zip:5 •ya."',i 0144 OZ1oc 4 Phone#: 7—q"--2)2—4138 Are you an employer?Check the appropriate box: Type of project(required): 1.1111I am a employer with employees(full and/or part-time).* 7. 0 New construction 2.01 am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.01 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 ❑Building addition 4.1.:I I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.❑Plu bing repairs or additions 5.0i am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.2<oof repairs The sub-contractors have employees and have workers'comp.insurance.: 6. We are a corporation and its officers have exercised their right of exemption per MGL c. 14.El Other 152,§I(4),and we have no employees.[No workers'comp.insurance required.] *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: 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 MGL c. 152,§25A is a criminal violation punishable by 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.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 perjury that the information provided above is true and correct. Signature: Date: / / Z-Z— Phone#: -q-4 -2-12.- 09 38 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: 0,"12/11e,--Ave,feez/(// /- Office of Consumer Affairs and Business Regulation 1000 Washington Street-Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Corporation Registration: 182000 CA.VINCENT,INC, - - Expiration: 05/17/2023 17 STILL BROOK RD SOUTH YARMOUTH,MA 02664 Update Address and Return Card. SCA a 2010-05;17 270fri‘e,e4,4seetemileirAtfa;ir/SA‘teette.fteitootision HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Corporation before the expiration date. if found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 182000 0517/2023 1000 Washington Street •Suite 710 CA,VINCENT.INC, Boston,MA 02118 'CHRISTOPHER 17 STILL BROOK RD SOUTH YARMOUTI-1.MA,140.64 Undersecretary Not valid without signature 1P. Commonwealth of Massachusetts Division of Occupational Licensure Board of Building Regulations and Standards Co nstkiR:tion SVpie,ry isQr •z:" CS-095633 ekpirec 0012012024 CHR1STOPHR A VINCtiT 7- . .. 17 STILL BROOK ROAD - SOUTH YARMOUTH MA 02664 ComrriiSt3i0t1Cr