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Home My WebLink AboutBLD-23-005792 BLD 40 .1,1. ca I J(C 9 )1a)23 O Office use only 4.- ,:'r 0 Permits CIO j�0r , ,, _ , Amount 9D.0e DO Permit expires 180 days from �0 —o?.3—579 z, issue date RECEIVED EXPRESS BUILDING PERMIT APPLICAT N - _ TOWN OF YARMOUTH APR 18'1O23 Yarmouth Building Department 1146Route28 BUILDING—DEPARTMENT Bye^ South Yarmouth, MA 02664 ---- — (508) 398-2231 Ext. 1261 :4:??t b CONSTRUCTION ADDRESS: 1 — .3 U`\r.. -,\- ,�� \-tAN' 5 Gin , ____ ,...\i"t5A- ASSESSOR'S INFORMATION: Map: Parcel: `0%'5(1/1: E 1) OWNER: '` V\S 0.,,� Co NS L ‘'402)5 U'y`olk 11. bNAME PRES ADDRESS � ^L. # CONTRACTOR: Y �/s' C.Cr\1. -Are., tt .�. E + W kke) ,- Cbt 30 -1 1 NAIvTE MAILING DRESS TEL.# D Residential mmercial Est.Cost of Construction$ 15 t t Home Improvement Contractor Lic.# t L`\ Construction Supervisor Lie.# e S'15c7.... Workman's Compensation Insurance: (check one)0 I am the homeowner D I am the sole proprietor 11.kave Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy# (AC(;' () r ?3 COOli e‘, WORK TO BE PERFORMED Tent 1:1 Duration (Fire Retardant Certificate attached?) Wood Stove El idin #of Squares IS Replacement windows:# Replacement doors: # Roofing: #of Squares (a)Remove existing*(max.2 layers) Insulation El ✓I Old Kings Highway/Historic Dist. ) Replacing like for like Pool fencing 1-1v u`vr ste\vlj lts - 1��e (IN A- 0- 4/7 1. , *The debris will be disposed of at: C.13C-(\,,,i.O l �,ric- ,,,Z., S'''Ty‘-\..1(r)1('-1.Location of Facility ` I declare under penalties of perjury :t e statements h-,, 'n 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 .- ' a: ' of my I' and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: p Date: IO ^[ Owners Signature(or attachment) i �/,�'-file t t� fie: !(f al Approved By: ate: �._/Z '2-"� Building Offic'• (or designee) I.ADDRESS: Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: ❑ Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No Commonwealth of Massachusetts Division of Occupational Licensure Board of Building Regulations and Standards Const,( `H errvisor CS-075281 fires:03/12/2025 TODD J CAN1ARI[.. , 10 ECHO RD*.. 1 WEST YARMIOPTtu •`, ,3 4.0/1 Vdi 0 Commissioner �iaQa f. 1&L!L THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Afflips,B Business Regulation HOME IMPROV ONTRACTOR i�ah. R sttp1ratign • 40140024 TODD CANTARA i b/B/A CANTARA }4f TODD CANTARA :' 10 ECHO RD. usl�L•�sGfos•�i W.YARMOUTH,MA 026744 : Undersecretary The Commonwealth of Massachusetts Department of Industrial Accidents 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. A licant Information PIease Print LeQibl Name (Business/Organization/Individual : c, `/`/�,'a �J• Address: City/State/Zip: --,--- Phone #: O 3 , Are you an employer?Check the appropriate box: I am a em to er with Z, Type of project(required): 1. ✓C employer employees(full and/or part-time).* 2. I am a sole proprietor or partnership and have no employees working for me in Jelin construction any capacity.[No workers'comp. insurance required.] 8. 7RemoelIg 3.E I am a homeowner doing all work myself. [No workers'comp. insurance required.]t 9. C Demolition 4.D I am a homeowner and will be hiring contractors to conduct all work on my property. I will 1 El Building addition ensure that all contractors either have workers'compensation insurance or are sole 11. Electrical repairs or additions proprietors with no employees. 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 1 ❑Plumbing repairs or additions These sub-contractors have employees and have workers'comp. insurance.: 13.El Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no employees. [No workers'comp. insurance required.] *Any applicant that checks box 4 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. lithe 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: Policy#or Self-ins.Lic. µ: b C(N aff<r,. ` Expiration Date: \ L'State/Zip: Job Site Address: �� ') �� Attach a copy of the workers' compensation P policy declaration page show ng 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 cent' der the pains and penalties of perjury that the information provided bone is true and correct. Signature: �— Phone Y: Date: L3 ?4-7 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#: