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Home My WebLink AboutBld-20-000441 • e Use Only Grp. L# �� -WO ,7 sr j4 0 Wit! Amount s Permit expires 180 days from issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 4e- 2 it-0/ ( (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: \ C\ �`� d'� � (4)LA\\...., ASSESSOR'S INFORMATION: Map: /7 Parcel: H7 OWNER: ICE PRESENT ADDRE TEL. cNV v!, \� CONTRACTOR: \ & `� l� 1� (Lo \/" tG � O` 1/4-" � r3" 3` NAME MAILING ADDRESS a TEL. esidential 0 Commercial Est.Cost of Construction$ �7 d Home Improvement Contractor Lic.# VCA\. Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) L I am the homeowner L I am the sole proprietor 'l 'I have Worker's Compensation Insurance p Insurance Company Name: 'N-,�, Worker's Comp.Policy# W DST \4116 `(� WORK TO BE PERFORMED I7 Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: #1_ 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: 1'��^rems «i (Grj Location of Facility 1 declare under penalties of pe.'u 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 deni. v •Lion of •license and for prosecution under M.G.L.Ch.268,Section 1. ::T;;; :: Si., // Date: `\ attachm. t) .�I/,� r �,d Date. • ' .�.44 f ' Approved By: Date: Building Official(or d sig EMAIL ADDRESS: Zoning District: Historical District: Yes No Flood Plain Zone: Yes i No Water Resource Protection District: Within 100 ft.of Wetlands: t] Yes No 1 Yes No The Commonwealth of Massachusetts Department of Industrial Accidents * ti :741. 1 Congress Street, Suite 100 i • _'=111:r= " Boston, MA 02114-2017 —� wwx.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): Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with 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. 0 Remodeling any capacity.[No workers'comp.insurance required.] 3. I am a homeowner doingall work t 9. ❑Demolition ❑ myself.[No workers'comp_insurance required.] 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.❑Plumbing repairs or additions 5.1:1 I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurances 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑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 pains and penalties of perjury that the information provided above is true and correct. Signature: Date: 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#: L . The Commonwealth of Massachusetts _,�'li�►_ / Department of Industrial Accidents t :R1= 1 1 Congress Street,Suite 100 Sill! + ' Boston, MA 02114-2017 yr www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Aonlicant Information \\ Please Print Legibly Name (Business/Organization/Individual): \�3 C _.c,,„'!\-c-4.--f— Address: 1( C` , 0 cZ%,. City/State/Zip: U , c,ft,,,s�,. ., Phone#: c t (i) —k.\S Are you an employer?Check the appropriate box: Type of project(required): I.�am a employer with Z— employees(full and/or part-time).* 7. 0 New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. ErRemodeling any capacity.[No workers'comp.insurance required.] 3. I am a homeowner doingall workmyself. t 9. ❑Demolition ❑ [No workers'comp.insurance required.] 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.❑Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.: 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§I(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 employee& Below is the policy and job site information. Insurance Company Name: t\ " Policy#or Self-ins.Lic.#: 4C ,,'V.)46 d'j Z..a V3 Expiration Date: 1 Z\2011 Job Site Address: CL.k C 17,.. :, V. ,ryZ, City/State/Zip:'S 1/41\A- 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 cer er th airs \LL,and penalties of perjury that the information provided above is tru and correctSi ature: ,� Date: 1 n 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): I.Board of Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: ` R / Y Commonwealth of Massachusetts ®� Division of Professional Licensure Board of Building Regulations and Standards Constr rilti5pervisor CS-075281 Spires:03/12/2021 TODD J CANTARA 10 ECHO RD � C WEST YARMOuv MA a 673 '> Commissioner • 4 Ae Womvmanurea / aoracA a/fit . Office of Consumer Affairs&Business Regulation • HOME IMPROVEMENT CONTRACTOR TYPE:Individual ReclistrOin, R6917.01121 TODD CANTARA '. DB/A CANTARA111ONS r i TODD CANTARA 10 ECHO RD. W.YARMOUTH,MA 0208Undeft eofet i y Registration valid for individual use only before the expiration date. If found return to: . Office of Consumer Affairs and Business Regulation. One Ashburton Place f.Suite 1301 Boston,MA 02108 Not valid without signature