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Home My WebLink AboutBLDX-25-1535 0Is Yq4 RECEIVED ! Office Use OnlyV 0 Permit# )(--oZ c ' jy NOV 17 2025 Amount ca5 y EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 49 Captain Besse Road, South Yarmouth, MA 02664 OWNER: Thomas Knapp and Ghanshyam Kaushalendra Mahendra Bhatt Trustees Knablat Realty Trust NAME PRESENT ADDRESS TEL. # CONTRACTOR: Kalstar Construction, PO Box 1780, Sandwich, MA 02563 508-685-5310 NAME MAILING ADDRESS TEL.# EMAIL: Mai.)SLta 116.-rt Lela Iwo, col .�1 Residential ❑Commercial ❑Est.Cost of Construction$ 20,000.00 Homeowner is Applicant? Yes X No Home Improvement Contractor Lic.# 174964 11/7/27 Construction Supervisor Lic.#CS-092859 7/10/27 WORK TO BE PERFORMED Tent No Duration 5 daYS (Fire Retardant Certificate required) Wood Stove Siding: #of Squares 27 Replacement windows:#1 1 Replacement doors: # Roofing: #of Squares 20 Insulation 0 Temporary Mobile Home Temporary Construction Trailer 0 Demolition—Interior only 0 'Demolition Raze Structure 0 Solar System 0 ESS System 0 Chimney 0 Fence 0 *Please submit utility disconnect letters for electric& gas—structures over 75 years old require historical review *The debris will be disposed of at: using Cavossa Dumpster Co. 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. �isa�rw waw°" wB9i we� y me K.m1a Applicant's Signature:_ "" 51 v.,EST ZIY!-W9,F-)N1.10-RF311 Owners Signature(or attachment)_9�*'��"'G �"B "° ��"a Approved By: Date: Building Official(or designee) Rev 6/24 dotloop signature venfica"° The Commonwealth of Massachusetts ate.\ Department of Industrial Accidents Office of Investigations Lafayette City Center Tartar • 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): Kaistar Construction Address: PO Box 1780 City/State/Zip:Sandwich, MA 02563 Phone#:508-685-5310 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. New construction employees (full and/or part-time).* have hired the sub-contractors 2.❑■ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have 8. [' Demolition working for me in any capacity. employees and have workers' q 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.❑■ Roof repairs insurance required.] + c. 152, §1(4),and we have no siding&window replacement employees. [No workers' 13.❑� Other comp. insurance required.] *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. tContractors 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 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 penalties of perjury that the information provided above is true and correct. dodoop verified 11/17/2511 42 AM EST Signature: NTMXLSRGW4DV-JXJD Phone#: 508-685-5310 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 20 Building Department 3❑City/Town Clerk 4.0 Electrical Inspector 5Elumbing Inspector 6.0Other Contact Person: Phone#: