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Home My WebLink AboutBLD-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