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Home My WebLink Aboutbld-20-003836 F�YR ti�O ceUseOnly �6 Rio i ,o i3 g 3 (C�, Amount MA7T.CM CS[ *'+bntto"4 �d,' !Permit expires 180 days from ;• -••'' {issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 /J (508) 398-2231 Ext. 1261 1 CONSTRUCTION ADDRESS: 47 � &r a AN€4 S+, S d"+^ Yar'µa IA 4 �1 ASSESSOR'S INFORMATION: 1 Map: Parcel: f'� G Q ry rta S iv eS 9�►4�.rr�yc®/v// 03106 &o3-3C I-0 3 7 OWNER: r °,�-� v N� PR $ t1F N v PRESENT ADDRESS TEL. # � CONTRACTOR: `.,[ •/• --e-h \( G` ( `( iv, �ro��1" sz% JJGi "1�,1 t NAME MAILING ADDRESS TEL.# 1 Residential 0 Commercial Est.Cost of Construction$$,2/ ,s2 0 O Home Improvement Contractor Lic.# Construction Supervisor Lic.# �;"411�Z ` Workman's Compensation Insurance: (check one) I am the homeowner am the sole proprietor I have Worker's Compensation Insurance p 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: # 2 Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing cfr-tc, *The debris will be disposed of at: () "'"r‘ "6' T1 'S 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 aid for➢rosecutio nder M.G.L.Ch.268,Section 1. / Applicant's Signature: . Date: l/ /O�aOp' D III Owners Signature(or attachment) Date: ///fU f�Q 20 Approved By: :004 �- Date: �-�� Buil : g Off or esignee) E DRESS: Zoning District: Historical District: 0 Yes C No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: ❑ Yes ❑ No ❑ Yes E. No The Commonwealth of Massachusetts Y �2 Department oflndustrialAccidents 1 Congress Street, Suite 100 • Boston, MA 02114-2017 '14f .• 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): —7;1v A C -". Address: cr-',\Ao City/State/Zip: k‘i ' c73,ti Phone 4: '167 Are you an employer?Check the appropriate box: Type of project(required): I.LAroram a employer with L employees(full and/or part-time).* 7. ❑New construction 2.2?am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp. insurance required.] _ 3. I am a homeowner doing all work myself. 9. _ Demolition ❑ y [No workers'comp. insurance required.]t 4.E1 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.E Electrical repairs or additions proprietors with no employees. 12.El Plumbing repairs or additions 6.❑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.l. 6.E We are a corporation and its officers have exercised their right of exemption per MGL c. 14.E Other 152,§1(4),and we have no employees. [No workers'comp. insurance required.] *Any applicant that checks box 41 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: vt 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 the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: 1 I Ca ' 7.C� Phone 4: 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 CIerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: v' Nl Commonwealth of Massachusetts Division of Professional Lieensure • Board of Building Regulations and Standards Constar iti p�rvisor CS-075281 Unires:03/12/2021 ' Ind Nv it I .fvTODD J CAA ' � H; 'RA 110 ECHO RD �G WEST YARMO j MA ,'a - ) Commissioner (132o tWo„monu oil a lac e%4 ' onic.at Consumer Af slrs A Business Regut alon • ;�;z? HOMEIMPROVEMENT CONTRACTOR tYP •.Individual 1fillit1. + 04109/2020 TODD CANT E ' t , . • • 'D/B/A CANTAO (?IONS TODD CANTARA 10 ECHO RD. , - W.YARMOUTH,MA-Wiwi` .. Undereecr or . Registration valid for Individual use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation One Ashburton Plate 4F Suite 1301 Boston,MA 02108 Not yalid without signature i •