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HomeMy WebLinkAboutbld-23-003737 O1.•YRR _Office Use Only I r ' '� r" e RECEIVED Permit# r ,, q //�� 3V r ,,,a,`�� �$ AN 1 J a2� ,Amount E: Permit expires 180 days from BUILD ING DEPARTMENT lissue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department l✓ '\ 23-0( 3737 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: rl Ce„ VeN)\IN c3 hc-e, V.e\�, CA r__r(fv.. L Jv A 1 ASSESSOR'S INFORMATION: Map: Parcel: OWNER: w NA�r _` 6 k`‘ 'PRESENT , ( �tNi cY,�\\. V I , . � , a Ste a�-\-1?0 ADDRESS TEL. #CONTRACTOR` C \�"C \ ADDRESS TEL.#Rdential 0 Commercial Est.Cost of Construction$ V.....,t 50b Home Improvement Contractor Lic.# VAS-NI ` Construction Supervisor Lic.# C3.) .,% (, Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor 0 I have Worker's Compensation Insurance Insurance Company Name: I. Worker's Comp.Policy# \('_ec CjSbq 2 AZ(A WORK'TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares 71,5 ( ) Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at Location of Facility I declare under penalties of perjury that the tatements 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 r>,s ..• .f my licens •Tor prosecution under M.G.L.Ch.268,Section I. Applicant's Signature: / - Date:Date: 0 1 ( o: \' 3 Owners Signature(or attachment) ', d 0) -AtAlTM Date: i( (vs Approved By: f ' ' i Date: / — /°) 23 Building 0 ial . desi: ee) E //ADDRESS: Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No a cL . t . +fir;; The Commonwealth of Massachusetts =, = Department of Industrial Accidents _ t 1 Congress Street, Suite 100 �= Boston, MA 02114-2017 -qv-Iwo* _ www.mass.gov/dia I'orkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): �u C v-, c Address: \ (:(G11,n City/State/Zip: `, ") Ir��o Phone #: •S- 6 3 (a) l�> Are you an employer?Check the appropriate box: Type of project(required): I. 1 am a employer with employees(full and/or part-time).* 7. E New construction 2.❑I 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.] 4.0 I am a homeowner and will be hiring contractors to conduct all work on m Y P roPertY• I will 10 Building addition . ensure that all contractors either have workers'compensation insurance or are sole 1 I.❑ Electrical repairs or additions proprietors with no employees. • 12.❑Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp.insurance.t 13.❑Roof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.©.elther ro t d 2�\G Ck� 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. 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: ibk,10.15, Policy#or Self-ins. Lic. #: Expiration Date: V2 Z3 Job Site Address: `7 Cc- 01 n � ��. City/State/Zip S 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$250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify un the pains and penalties of perjury that the information provided above is true and correct. s� Signature: Date: ell 0't Phone#: c-C) k Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License# Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: Commonwealth of Massachusetts Ili Division of Professional Licensure Board of Budding Regulations and Standards Cons`ivjM't rvisor CS-075281 `�: 15 Aires:03/12/2023 TODD J CANARA .. 10 ECHO RD-r, f '" WEST YARMOjJTH MA 02673 t O til -10 kvo,Svl30 Commissioner daea K. 8' aa.. THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE_"Individual Reg_istr_at_ -_ Ex 159�11 • j ration DOT CANTARA �_ /09/2024 D/B/A CANTARA HO,IgE i TODD CANTARA c _$ _ 10 ECHO RD. W. YARMOUT .x_7 ''' H,MA 02673f4 z.' '` f�f�n..'°t'CL., Undersecretary