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Home My WebLink AboutBLD-23-002219 Q1'•YeyR Office Use Only �w• moo: ( m �7 L ) j /' Permit# (�� r� O : I �4 . H; O -- :.�, I x; Amount MATTACn ESE ��•a..Eo. `d: Permit expires 180 days from issue date 6L-/- a3 ad - -l1 EXPRESS BUILDING PERMIT APPLI TOWN OF YAROUTH - . °._. M .a __ ._ _ ' ,1 Yarmouth Building Department 1146 Route 28 L?CT 25 2022 1 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 BUILDING DEPARTMENT CONSTRUCTION ADDRESS: I l'i PIGES4n I" Wed" ASSESSOR'S INFORMATION: rk. Map: Parcel: OWNER: N41st be 44.031.1 ( '1 Plci.c 4 S4Deck So..W y4,0"o•4.1%, NI' Sc - iC, —015 NAME 1- PRESENT ADDRESS TEL. # CONTRACTOR: 5+eQ n L CAtvvs !`IS V4II6, (,I elsrtuw%.t,,t1(4 s g-360-0,1 v NAME MAILING ADDRESS TEL.# L esidential ❑Commercial Est.Cost of Construction$ g 0 Q O,,OD Home Improvement Contractor Lic.# Iei001). Construction Supervisor Lic.# CS-osivic) • Workman's Compensation Insurance: (che one) ❑ I am the homeowner 1i'am 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 ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: r&OW'if'. TfbAS'Re' 4•tu.. a O 1 MA(A44 ..ir (9 vol Location of Facility I declare under penalties of perjury.that the statements herein contained are rue an orrect to the best of my knowledge and belief. I understand that any false answer(s) will be just cause for denial or r�tion of m license and for p ec ti nder . .L.Ch.268,Section 1. Applicant's Signature: Date: io/,75I 2 Owners Signature(or attachment) / Date: I01151)3 Approved By: .- Date: /4 2 Building Official es. e EMAIL ADD . Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No L.U-a- Water Resource Protection District: Within 100 ft.of Wetlands: � , ❑ Yes 0 No ❑ Yes ❑ No r/ l I "/ -0219 c1— L *T" Demo - C4,6;w4 , b f fl, FL,— e4. • The Commonwealth of Massachusetts 17. Department oflndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 5'•`''� www.mass.gov/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): Se4wu,-.- 1 PfUeAl*s Address: ?fso rS N.A.( 130 s-k . -!: 2l). City/State/Zip: cres441<, r►A, oX .4'-1 Phone #: 719 Ai-21°3 Are you an employer?Check the appropriate box: Type of project(required): 1.E]I am a employer with employees(full and/or part-time).* 7. New construction tole proprietor or partnership and have no employees working for me in any capacity. [No workers'comp. insurance required.] 8. Remodeling 3.❑I am a homeowner doing all work myself. 9. C�— Olition y [No workers'comp. insurance required.] 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 n Building addItiOn ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.11 Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp. insurance.1 13.Q Roof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.l I 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. 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 ains and penalties of perjury that the information provided above is true and correct. Signature: /% ✓ C Date: lU11S�� Phone#: ?-r-()by-zto g 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#: ; Commonwealthl of Massachusetts r Division of Professional Licensure Board of Building Regulations and Standards Constru t S tti' pnrisor CS-088961 ti: 71 �,e� A, 6cpires:09/2A.7/2023 STEPHEN L 1TAR m ,: 145 VALLEY ROAD ,`+ ,, C j PLYMOUTH NO. 023i ! : . 4. Commissioner daea K. T�tnri,4 Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Individual Registration Expiration 190072 12/17/2022 • STEPHEN L CATARIUS • STEPHEN L.CATARIUS %? 10 SHAWME RD '.,,.,,elf1 !fzflo,,,4' SANDWICH,MA 02563 Undersecretary Construction Supervisor Unrestricted-Buildings of any use group which contain less than 35,000 cubic feet(991 cubic meters)of enclosed space. Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. For information about this license Call(617)727-3200 or visit www.mass.gov/dpi Registration valid for individual use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 1000 Washington Street -Suite 710 Boston,MA 02118 vali without signature