BLD-23-002407 4.;�,q - ` G�_i 1((/3/&? Office Use Only
O �t�Rp Permit# e%#33�
0 +_ v H Amount go, Q
F NA .fi„ 4'
e"""c'�c��' Permit expires 180 days from
.; issue date
61_-1w-013 -6
EXPRESS BUILDING PERMIT APPLICATION 000VC)?
TOWN OF YARMOUTH RECEIVED
Yarmouth Building Department --_•.___-•____^�
1146 Route 28 Lt21.0V 01 2022
South Yarmouth, MA 02664 _ _(508) 398-2231 Ext. 1261 BUILDING DEPARTMENT
I� �.{�C�U BY
CONSTRUCTION ADDRESS: OC
C 3`\ C1 tr lJ ��JJ 1 J
ASSESSOR'S INFORMATION: ( '' \rw134-4/$
`�[/�` Map: Parcel: �--0%)(4Z_ 1 D
OWNER: ` y V�.0i on Coa\NSPRES TALt \40DDRESS)5 CiC"?tkkjA y1-- oNAME �
CONTRACTOR: r �i•' �(��t-„ram (6 C Q , W\k�c, ,,p�-�,� �IS 3 L? itSI f
NAME MAILING ADDRESS TEL.#
0 Residential ommercial Est.Cost of Construction$ iQt6 60
Home Improvement Contractor Lic.# lS\L\\ Construction Supervisor Lic.# C�' S.-Lg
Workman's Compensation Insurance: (check one)
0 I am the homeowner 0 I am the sole proprietor 11,14tave Worker's Compensation Insurance
Insurance Company Name: TN .f Worker's Comp.Policy# cc,' O'CA7 3 t c )' P�
WORK TO BE PERFORMED
Tent El Duration (Fire Retardant Certificate attached?) Wood Stove
Siding;.#of Squares ` Replacement windows: # Replacement doors: #
Roofing: #of Squares (E) Remove existing* (max.2 layers) Insulation I I
I ✓ • Old Kings Highway/Historic Dist. co
)Replacing like for like Pool fencing
0M1le ua tn‘Y 5 ti — \ oi. )( 1\)[2 `(- 1 "t,� ..4144't ''/ 7/2i2
*The debris will be disposed of at: JC---r\v.l3 L.KVAr, —17r-- v�� ,Ol?r•-/
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, n of my Ii - e and for prosecution under M.G.L.Ch.268,Section I.
Applicant's Signature: `111.21l' 44 Date:
Owners Signat e(or attac ,�!IV I?(J �al e Bate: ib, u'' /
Approved By: i _ -/��j1' Date: `//�/
Buil.mg O c a- or des<' EMAIL ADDRESS: ///
C Zoning District:
Historical District: Yes No Flood Plain Zone: Yes No
Water Resource Protection District: Within 100 ft.of Wetlands:
Yes No Yes No
The Commonwealth of Massachusetts
--- L Department of Industrial Accidents
win= 1 Congress Street, Suite 100
It M= Boston, MA 02114-2017
-imp www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
1
Name (Business/Organization/Individual): 1 h ,.�, tr\ .r�.S-+�.
Address: 4?,A
City/State/Zip:�,.i � � r/-CC tO J'ip'\ Phone #: 5-OZ
Are you an employer?Check the appropriate box: Type of project(required):
1.1:e'ram a employer with (4 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. E 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 YP roPrh'•
e I will 10 Building addition
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.❑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.t
6.0 We area corporation and its officers have exercised their right of exemption per MGL c 14.(c. ther
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 ant 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. #: CC, 0 k" b<I bt 4 Expiration Date: la Z
Job Site Address:TZt4.4 \4 e,. City/State/Zip: icr4vpki - bA
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$250.00 a
day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby cer ' he pains and penalties of perjury that the information provided above is true'and correct.
Signature: Date: VP--
Phone#: \
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: _Permit/License#
Issuing Authority (circle one):
I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone#:
Commonwealth of Massachusetts
® Division of Professional Licensure
Board of Building Regulations and Standards
ConstikjhI`* t11 ,rvisor
11.
CS-075281 spires:03/12/2023
TODD J CANTARA
10 ECHO RD-, ,? ,-1
WEST YARMQ11TH MA 7 3 •'
Commissioner dada K. FiEn ,
THE COMMONWEALTH OF MASSACHUSETTS
Office of Consumer Affairs$Business Regulatio
HOME IMPROVEMENT CONTRACTOR n
TYPE; vidual
Reois_: tration .
153�11� I►ation
TODD CANTARA iD91_2024
D/B/A CANTARA HOME'S()
TODD CANTARA
10 ECHO RD.
W. YARMOUTH,MA 02673;
Undersecretary