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Home My WebLink AboutBLD-23-003431 t ,,Office Use Only Y R P ; F i V P 1 Permit# L'`llrl-1 �3 0 z si i e Amount q0. GEC 2 C 2022 � - Permit expires 180 days from .. e issue date BUILDING 12EPARTMENT I By __ 6o—oz34p3L/3 / EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext 1261 '' n(Jk, \ � CONSTRUCTION ADDRESS: (L. L I 0�\ (r1ê&#' WO\v ASSESSOR'S INFORMATION: '1/4- e-kw'0" ka A t' Map: Parcel: "50%)l47.,_ ) 1 D • ` yam, 1-,< OWNER: ! y. .4> ,� 0 ,� (�`1. VX Q5 CI«knk ,.t... e()� NAME PRES �T(AD�DRESSS EL. # • �T -- CONTRACTOR: �[i i&- C am- '„ ^ jJ ��►^(�� AZ , 1 �atfir�-. ��A,L � ,- (--i j t\ 1 NAME MAILING ADDRESS TEL.# xx y� 0 Residential ommercial Est.Cost of Construction$ 1' U vU �Z..,` _S \ Home Improvement Contractor Lic.# � Construction Supervisor Lic.# \ c-i J 1 Z...-J Workman's Compensation Insurance: (check one)0 I am the homeowner,[ CI am the sole proprietor O k4ave Worker's Compensation Insurance 1-\ Insurance Company Name: Worker's Comp.Policy# Acc7S(')'4L)0 3 t)S i.e `„, WORK TO BE PERFORMED Tent 0 Duration (Fire Retardant Certificate attached?) Wood Stove iding,)#of Squares 16 Replacement windows: # Replacement doors: # Roofing: #of Squares (❑)Remove existing* (max.2 layers) Insulation I J Old Kings Highway/Historic Dist. Replacing like for like Pool fencing I 1 k \ a�) �1\V j 0 — \ tV.e �;i\)ct o`� al /.z_ 'The debris will be disposed of at: C-jc--r o t AA- \ .rSks `'"'1(-"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 Ii and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: /Z '1 77 Owners Signature(or attachment) te: irAZ j'zei: //°'" l Approved By: Building Official(o sign EMAIL AD SS: Zoning District: Historical District: Yes No Flood Plain Zone: Yes No Water Resource Protection District: Within 100 ft.of Wetlands: Yes No • Yes No I.. Commonwealth of Massachusetts Division of Professional Licensure Ilf Beard of Building Regulations and Standards Cons...! tA0 rvisor *zi.1 ,1 CS-075281 •-• ,-, "' , spires:03/12/2023 - TODD J DAN*RAz„, 10 ECHO RD7.1.1- WEST YARM0,114 ' ' , a •;'-'7':. NT 0/S410A ,_ .. Commissioner claia. K. 'Ekon-Wt. ./ Office THE M oCf0CM0 Consumer ALTH 0,8iF BMuAsSinSAessCHRUeSETTulation S HOME IMPROVEWOONTRACTOgR 1 .,.g-.• vIciPat, R t_itgortIsii: _. . I n ; TODD CANTARA s_.....:.! --t-----2..._ , ,•:- ,---2 ,-,77-4 '';' 1 D/B/A CANTARA HOME ... i• 7 — TODD CANTARA 1:771-- W. yEACRH mOoRuDT. H,MA 026 /;/ Undersecretary, ,..__ The Commonwealth of Massachusetts 111- i-• '� Department of Industrial Accidents jii= ' 1 Congress Street, Suite 100 e 7.44--_ ` j Boston, MA 02114-2017 .�y � 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): t n,x,4, 04-D. Address: 1't ; 4 • City/State/Zip: .r4 t,"'S rrC"wkOt.' L i ,''ti k Phone #: Ota W) --m-k Are you an employer?Check the appropriate box: Type of project(required): I.2<alm a employer with L( employees(full and/or part-time).* 7. ❑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.] ' 3.0I am a homeowner doingall work myself. 9. 0 Demolition y [No workers'comp.insurance required.]t 10 ❑ Building addition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will . ensure that all contractors either have workers'compensation insurance or are sole 11.0 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 13.0 Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 603 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. I4.Ego6ther 44, 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 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: ,ML, Policy#or Self-ins.Lic.#: \,.tCC 'S 0 c-61 ..')n b 2,O1% 4 Expiration Date: (7.\Zit. Job Site Address: tv.o)�s vV a. City/State/Zip: 'Icrrtstoikotktkribel 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(rue'and correct. Signature:.,r. Date: lZ.\7,6 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 Contact Person: Phone#: