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Home My WebLink AboutBLD-23-002400 ~ .O�,YRR,1 / y�/� /J'A^J 1'v' ;Office Use Only f ? (' ,I , ' Permit#( 4.4 ' C I1/3/?1L p ///7J2 Ou. • H 'Amount .DO L MATTAC11 CSC . I % .4..„NaLO cad Permit expires 180 days from lissue date 6L4o -013 -JOB1/60 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department RECEIVED 1146 Route 28 -- ---- South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 NOV 01 2022 CONSTRUCTION ADDRESS: I N Flea WA S rtti- BUILDING DEPARTMENT t . ASSESSOR'S INFORMATION: Map: Parcel: OWNER: R0644 cqui N.:At.-( av+.#iwlk 139 Pkas l- S+• Suitt `&si...l1,HA Jr)$-T (S O4115 NAME PRESENT ADDRESS TEL. # CONTRACTOR: tit L. ( hva iS ail S Valle`( eI•I 4,HII. 511-110-1140 NAME MAILING ADDRESS TEL.# li'Residential 0 Commercial Est.Cost of Construction$ I1 U Home Improvement Contractor Lic.# 19o012 Construction Supervisor Lic.# CS"0 3 Y`1(01 Workman's Compensation Insurance: (check one) 0 I am the homeowner ,7,6.1<m the sole proprietor 0 I have Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy# WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows: # Replacement doors: # Roofing: #of Squares jO ( Remove existing* (max. 2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: 'JG..w'YtC WkSk t i 4aytrwtn'- - ,i:%1 elk,.µr44wr B1 vJ 13 ..d-n , NK 03 S 3 2 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 1. Applicant's Signature: ZI_____ Date: Ili 1 I J.) Owners Signature achment) Date: /V J Z- j Z Approved By: ' ' Date: //`5 2 Z_ Building 0 gn ) EMAIL ADDRESS: Zoning District: Historical District: 0 Yes ❑ No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 2 No The Commonwealth of Massachusetts • ► - / Department of Industrial Accidents 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 Please Print Legibly Name (Business/Organization/Individual): Se.»w„^4h 1 Pri ve--1 i s LLv` Address: VicA3 ilu'k i3,) s.ali 2 . la City/State/Zip: s tkic, hfa v-NO-e-t Phone #: -21Q 3 Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with employees(full and/or part-time).* 7. New construction 2 1g-I am a sole proprietor or partnership and have no employees working for me in 8. 7 Remodeling any capacity. [No workers'comp. insurance required.] 9. ❑ Demolition 3.0 I am a homeowner doing all work myself. [No workers'comp. insurance required.]t 10 Building addition 4.❑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. • 12.111 Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.RR of repairs These sub-contractors have employees and have workers'comp. insurance.t 6.11 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.[1]Other 152,§1(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. r 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: 11(11)J Phone#: 7741 -) -)" 3 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#: • Commonwealth of Massachusetts Division of Professional Licensure Board of Building Re ulations and Standards Constsr,0 ri rvisor'• CS-088962 ti ,spires:09/27/2023 STEPHEN L FIT ; f 146 VALLEYtOA i PLYMOUTH t' >/„N .x t, ()It`,ti cliCO Commissioner do fi. DCvncita. • Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Individual Reaistratim fxoIration 190072 12/17/2022 STEPHEN L CATARIUS STEPHEN L.CATARIUS 10 SHAWME RD ib SANDWICH,MA 02563 Undersecretary I'4