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HomeMy WebLinkAboutBld-20-000412 Ju1.25.2019 07 :37 PM PAGE. 1/ 1 ' Okl9 jthe Only} 1 , •s A ::' 0 Pei `a'YJ ut+'U' I'' M N 4' � Amount Permit expires 180 days Itom , issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH • Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 # "V (508) 398-2231 Ext. 1261 A-eso CONSTRUCTION ADDRESS: Lid% \N(N7 RX S , \-'>,e-r-c,-Dk" ASSESSOR'S INFORMATION: Map; Parcel: OWNER: kark ``\e.. V`'1 \41,/- , M SI‘'e^ ‘R ... Q.,\,,p.r\Xx r� V 1 1 NAME PRESENT ADDRESS TEL y I CONTRACTOR: A N � Ccr \ V„c, ` Wt 4'`rt,rr JU�SO \\ MAILING ADDRESS T L M ierResidontial 0 Commercial 1 Est.Cost of Construction S 2 aC, Home Improvement Contractor Lie.i `S \Z\ ` Construction Supervisor Wc.StOr[15R`?j Workman's Compensation Insurance: (check one) L I am the homeowner Li I� am the sole proprietor n mave Worker's Compensation Insurance �-� Insurance Company Name; 1 1_ ` Worker's Comp.Policy, W C �V SO 6 V (C)S ao y 18 WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: tI 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 ear....A? ---77_____ ,11 Location of Paclilty 1 declare under penalties- pe ' ry that the statements herein contained are true and correct to the best of my knowledge and belief. 1 understand that any false answer(s) will be just cause for .-• C vocation of my license and for prosecution under M•O,L.Ch.268,Section 1. Applicant's Sign, • e: . - AMP Da. 1 w Owners Sig alum(or Otte hment) �_,___ �,.,.___ _Dahl ' 11,111111111111111. Approved By: 1'- A4i Date: G /7 Building Officia *r `; EMAIL ADDRESS: r Zoning District; _ Historical District: (.I Yes 0 No Flood Plain Zone: CI Yes r.i No Water Resource Protection District: Within 100 ft.of Wetlands: I"1 Yes IJ No 0 Yes 0 No The Commonwealth of Massachusetts i =�= 1— !/ Department of IndustrialAccidents _:1►1_ 1 Congress Street,Suite 100 111 Boston, MA 02114-2017 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):-,, \ .ti4c--0 Address: \© cc N `e� City/State/Zip: , �,,�, Phone#: Are you an employer?Check the appropriate box: Type of project(required): l.[2(am a employer with V employees(full and/or part-time).* 7. ❑New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. 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 0 Building addition 4,0 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 11.0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.01 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.El 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: L Policy#or Self-ins.Lic.#: W l) 17 2,6k �, Expiration Date: Job Site Address:Z , V"bl�c�1 ,� , City/State/Zip:S��zlCrJ� J Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration dite). 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 cer)a ' r t pains and penalties of perjury that the information provided abo a is tr a and correct. Signature: ate: Phone#: ( 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 }®iDivision of Professional Licensure Board of Building Regulations and Standards ConstriXtllri%i_i'pervisor CS-075281 4pires:03/12/2021 11, TODD J CANTARA 10 ECHO RD O WEST YARM01131 MA 6.73 Commissioner CAL dlieWorn-manwea/1%ofPfiemaac%uaeta `-• Office of Consumer Affairs Si Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Individual AdsOQp Expir n 18Q21-1 04/09/2020 TODD CANTARA DB/A CANTARAIIO1 iTIONS TODD CANTARA 10 ECHO RD. W.YARMOUTH,MA 02678 Undersecretpry Registration valid for individual use only, before the expiration date. If found return to: _ Office of Consumer Affairs and Business Regulation r One Ashburton Place*Suite 1301 Boston,MA 02108 Not valid without signature