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Home My WebLink AboutBLD-23-002654 Cr 0�/ 1� -I S - 22_ Office Use Only S�4 V A,-- Permit# C9 e-33 jilO �+l,� H: Amount 90 06 ....,,‹....$,„, Permit expires 180 days from issue date 8LD-a3-ONO su EXPRESS BUILDING PERMIT APPLICAT -_E i \/ - a TOWN OF YARMOUTH NOV 14 2022 Yarmouth Building Department 1146 Route 28 BUILDING South Yarmouth, MA 02664 a DEPARTMENT (508) 398-2231 Ext. 1261 `J' v CONSTRUCTION ADDRESS: 2-C6 3 �At v 0 V(, � \Z,‘ W, k.:-/ ASSESSOR'S INFORMATION: `�` Map: Parcel: '50%)( _-�1 D OWNER: \ V V�1S V"O ��NJPRES �A RESS)" (lc?lik 1-.4L.,-"fa..TEL. ° , CONTRACTOR: '-"Xi Cro,/,--\- „rZ• ( AILINL R SS - k t A . # co() 3( -it 1 ❑Residential ommercial Est.Cost of Construction$ Z(ipt) Home Improvement Contractor Lic.# `crkZ,`\ Construction Supervisor Lic.# CS')c L'S Workman's Compensation Insurance: (check one) 0 1 am the homeowner 0 I am the sole proprietor ❑,,,Yitave Worker's Compensation Insurance Insurance Company Name: I \ .f. Worker's Comp.Policy L4cc t�c c)3 io1e e WORK TO BE PERFORMED Tent El Duration (Fire Retardant Certificate attached?) Wood Stove El iding;, #of Squares 'a Replacement windows: # Replacement doors: # Roofing: #of Squares (0) Remove existing* (max.2 layers) Insulation I I Old Kings Highway/Historic Dist. ) Replacing like for like Pool fencing 01.e C`a"✓ >vt‘V1i (Zs- — 1 " l 1)62_ cic-- yrt 41 7/7� *The debris will be disposed of at: J�\„nl�t -f- \((),(` 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 o n of my li e and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: / Date: Owners Signature(or attachment) ,Gt , l�L e ifral _Dee: Approved By: �(/ _i; - Date: //l'/7 �2- Building Official,( ign , EMAIL ADDR Zoning District: Historical District: Yes No Flood Plain Zone: Yes L No Water Resource Protection District: Within 100 ft.of Wetlands: Yes No Yes No The Common wealth of Massachusetts - — L Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 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): Address: 1t) ; ,o City/State/Zip: 11A Phone #: cata, --``cCk Are you an employer?Check the appropriate box: Type of project(required): I.Rram 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 work ng for me in 8. 7 Remodeling any capacity.[No workers'comp.insurance required.] 3.Q I am a homeowner doing all work myself. [No workers'comp. insurance required.]t 9. E Demolition 4.0 I am a homeowner and will be hiring contractors to conduct all wcrk on mYPropm'• e I will 10 Building addition . ensure that all contractors either have workers'compensation insurance or are sole 11.C Electrical repairs or additions proprietors with no employees. 12.E 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.; 13. Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.[ ther cA.V 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 showine 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: kiv\-t. Policy#or Self-ins. Lic. #: `,,JCc, ' S(-) T bS 1 61% 4 Expiration Date: (1 1 Job Site Address:\t .4 \4e ) City/State/Zip: yc...crA/o bC� 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$250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cer ' he pains and penalties of perjury that the information provided above is true'and correct. S ignature: c Date: //( zi' Phone#: R (((((( Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License# Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: Commonwealth of Massachusetts Division of Professional Licensure Beard of Cons Building RegulationsSS and isor Standards } it 1 ,rvfl CS-075281 Tcpires:03/12/2023 TODD J CANTARA 10 ECHO RD1` `~ WEST YARMiTH MA 02673 r '�/')iSS 1:1O1`. Commissioner dais THE COMMONWEALTH OF MASSACHUSETTi Office of Consumer Affair%$Business HOME IMPROVEMENT CONT Regulation TYPE; Regulation Re i �d+vidual Ex iration TODD CANTARA _ D/B/A CANTARA HOME _ 7ODDC � c- �._ 10 ECHO RD. "':11:e4a..i� - �=:YAR MOUTH,MA02` �-N Undersecretary