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Home My WebLink AboutBLDX-26-1174 application Y Office Use Only O `94A Z► TO Permit#( '�� D-'k 1 LA -1 y Amount CI 0 9 HCO•To RA-to\yA EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 (508)398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 817 Route 28 Yarmouth Ma 02673 Unit 14 OWNER: Captain Gladcliff LLC NAME PRESENT ADDRESS TEL. # CONTRACTOR: Mold Doctors 572 Rte 28 Yarmouth Ma 02673 508-534-9091 NAME MAILING ADDRESS TEL.# EMAIL: info@molddoctors.net ❑Residential 0 Commercial ❑Est.Cost of Construction$1000.00 * Homeowner is Applicant? Yes No Home Improvement Contractor Lic.#172980 Construction Supervisor Lic.# 108984 WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate required) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares Insulation Temporary Mobile Home Temporary Construction Trailer Demolition—Interior only X *Demolition Raze Structure Solar System__ ESS System Chimney Fence *Please submit utility disconnect letters for electric&gas—structures over 75 years old require historical review *The debris will be disposed of at: Yarmouth Dump 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 revoc . of my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature:_ Date: t J - ")._� Owners Signature(or attachment),RC/t V, IlkDate: i 0— a---,QOp2^tJ Approved By: Date: Building Official(or designee) . @� Rev 6/24 R E C E R E C E IV OCT 0 2026 OCT i t BUILDING DEPART J ppp ey. BUIL G DEPARTMENT By. The Commonwealth of Massachusetts • ' Department of Industrial Accidents ( Office of Investigations w - \ t i I y Lafayette City Center 2 Avenue de Lafayette,Boston,MA 02111-1750 wmv.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual):Martinello&Moms Inc DBA Mold Doctors Address:572 Rte 28 City/State/Zip:Yarmouth Ma 02673 Phone#:508-534-9091 Are you an employer?Check the appropriate box: Type of project(required): l.■❑I am a employer with 10 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 workingfor me in anycapacity. employees and have workers' P tY• 9. ❑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.❑Plumbing repairs or additions myself.[No workers'comp. right of exemption per MGL 12.0 Roof repairs insurance required.]t c.152,§I(4),and we have no employees.[No workers' 13.0 Other 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:Aim Mutuial Insurance Policy#or Self-ins.Lic.#:WCC 500 8255360 2026A Expiration Date:7/8/2027 Job Site Address:817 Rte 28 Unit 14 City/State/Zip:Yarmouth Ma 02673 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 the pains and penalties of perjury that the information provided above is true and correct. �:::nature: Date: \O a• Phone#: Ob Cv-\y- \—l'-\to 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): 112Board of Health 20 Building Department 30City/Town Clerk 4.0 Electrical Inspector 50Plumbing Inspector 6.0Other Contact Person: Phone#: Commonwealth of Massachusetts Construction Supervisor il Division of Occupational Licensure Unrestricted -Buildings of any use group which contain less than Board of Building Regulations and Standards 35,000 cubic feet(991 cubic meters) of enclosed space. HT Cons`tr ion-gti'prvisor CS-108984 � � .,Y spires: 03111/2027 FRANK V FEPERIC* t,- -.; r 7 KIRKLANC1T + ' . . SAUGUS MA:91906 ' rim) r ?t,� >0 UIJHds�> N Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. Commissioner c i p5�� Contact OPSI: (617) 727-3200 or visit www.mass.gov/dpl/opsi Home(Is/) Contractor Log In Vs/contractor-login) Contractor Search Tool(/s/hic-contractor-search) Submit Complaint(/s/submit-a-complaint) An official website of the Commonwealth of Massachusetts Here's how you know Search Contractor Registration and History MARTINELLO&MORRIS,INC. Registration Status:Active Information Related Businesses Guaranty Fund Claims Public Complaints Arbitration Case History Business&Address Information Business Name:MARTINELLO&MORRIS,INC. Phone:5089441746 Mailing Address: 38 Wilson Road W.YARMOUTH,Massachusetts 02673 Physical Address: 38 Wilson Road W.YARMOUTH,Massachusetts 02673 Registration Information HIC Number.172980 Registration Status:Active Effective Date:2026-08-21 Expiration Date:2028-08-21 Responsible Person Details Name:Michael Martinello Email:mike@molddoctors.net y S.y, �? Office of Consumer Affairs and Business Regulation I Home Improvement Contractor Program • 1 Federal Street,Suite 0720,Boston,MA 02110-2012 Enterprise Information Technology Accessibility Policy(httDs//www.mass,aovioolicy-ashdsory/enterprise-information-technology-accessibility-policy#policy-statement7) /j I r o _ 'X 1 <7C C ' 4. r r s c nr V s S i4 il B.6({ 6r11 it, f b1(4,:e,"`I s .