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Home My WebLink AboutBLD-23-001528 BLD 98 , cal ice' C J I Z2_ Office Use Only 01. 1) CAL ) Permit# .iti ' O 0 ��T Amount qfi',(lb c' Permit expires 180 days from �.. /s t J� :)3_6 6/ -�issue date (� �/ ;a RECEIVED EXPRESS BUILDING PERMIT APPLICATI I --- ----- TOWN OF YARMOUTH SEP 2 0 2022 Yarmouth Building Department 1146 Route 28 BUILDING DEPARTMENT By _ South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 \ -VX, q& CONSTRUCTION ADDRESS: l(-1 - \ Ve� c�,." Val Y5 ASSESSOR'S INFORMATION: Map: Parcel: ,r )(.+2.— )-5t D OWNER: \ - y 4, � , a. �� L \„ t \\1'Q5 ( A ikn 1...,<,.._ ,,e‘ NAME (�' _� t PRESrr T ADDRE$SS�S - TEL # _ CONTRACTOR: �1s c`i&- C r re \MAILING ADDRESS' \ J ki 1 ic.i"TEL.# ') S (1-7 —1 t`) 1 NAME 0 Residential ommercial Est.Cost of Construction$ 181066 1 Home Improvement Contractor Lic.# `c L\\ Construction Supervisor Lic.# ( i cLS Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor lYtave Worker's Compensation Insurance i l Insurance Company Name: 1\�� Worker's Comp.Policy# (iC� c A-7 0 uyto 15, t` WORK TO BE PERFORMED Tent 0 Duration (Fire Retardant Certificate attached?) Wood Stove (Sid-i,)#of Squares I.8 Replacement windows:# Replacement doors: # Roofing: #of Squares (❑)Remove existing* (max.2 layers) Insulation I I r-2/ Old Kings Highway/Historic Dist. Replacing like for like Pool fencing i I l2 Ce XW stn\05 tL; - 1 o� t$ - ov-- ,�144- 41 -1/2 `The deb is will be disposed of at: r G t t '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 o ' n of my li and for prosecution under M.G.L.Ch.268,Section 1. Date: q c1,6\-Zit Applicant's Signature: r /� \ \ f �t21 ate: Q\Z6\o ' Owners Signature(or attachment) 1 li 2 �22 Date Approved By: Building Official(or design EMAIL ADDRESS: 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 V —p Department of Industrial Accidents _ != 1 Congress Street, Suite 100 •"•�= -L Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Annlicant Information Please Print Legibly Name (Business/Organization/Individual): 1 ru:‘.4, C,'_c,,c •: Address: k`b �~, ,� 'Q�r • City/State/Zip:�,�l �� tr,t'�urbl� J''NA Phone#: 5 t3 Are you an employer?Check the appropriate box: Type of project(required): 1.1 am a employer with t••( employees(full and/or part-time).* 7. 0 New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t g Demolition❑ 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 0 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees.` . - 12.0 Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.Q Roof repairs These sub-contractors have employees and have workers'comp:insurance.r 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.g•other 5t 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 an:an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: ,M` Policy#or Self-ins.Lic.#: jCC, '10 chr j 2,01% q Expiration Date: (Z 1 Job Site Address:\ W 0%.;-) City/State/Zip: 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 c he pains and penalties of perjury that the information provided above is true and correct. S. ature: �.. ate: 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): 1.Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Phone#: Contact Person: Commonwealth of Massachusetts IPrDivision of. Professional Licensure Bdard of Building Regulations and Standards Consti u t Isor CS-075281 _° Spires:03/12/2023 TODD J CANTARA 10 ECHO RD-:3 v WEST YARMON Commissioner d, 0• K. F.I`rrc , THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation Registration valid for individual use only before the expiration date. If found return to: HOME IMPROVONTRACTOR Office of Consumer Affairs and Business Regulation TtieYP i Expirhat:; 1000 Washington Street -Suite 710 — ` 14I3, 4; 4n Boston,MA 02118 . ,��srrr U2 1 r L.. : ', TODD CANTARA D/B/A CANTARA HOME TODD CANTARA ` 10 ECHO RD. W.YARMOUTH,MA 0207, _. . Undersecretary Not valid without signature