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EXPRESS BUILDING PERMIT APPLICATI r.... F C E I y E R.I
TOWN OF YARMOUTH
Yarmouth Building Department SEP 07 2022
1146 Route 28
South Yarmouth, MA 02664 UILDING DEPARTMENT
(508) 398-2231 Ext. 1261 v
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CONSTRUCTION ADDRESS: O"
ASSESSOR'S INFORMATION:
Map: Parcel: .50%)(;2-351 D f
OWNER: ` '..N.V\SIP (L.') CO•f\N \< / C-( 1LiA �NAME PREcALt,
T ADDRESS
CONTRACTOR: ' Y �i. . C ,, "..�` `M AIez ADDRESS, ` ), At_1 L. cbt 3 1 t,1
NAME
0 Residential ommercial Est.Cost of Construction$ ( 0 D Ot)
\ Home Improvement Contractor Lic.# \ `1L� Construction Supervisor Lic.# C(:)7 S.-Z-S
Workman's Compensation Insurance: (check one)
0 I am the homeowner 0 I am the sole proprietor grave Worker's Compensation Insurance Insurance Company Name: J- Worker's Comp.Policy# c omit)0 3 t1
ev
WORK TO BE PERFORMED n
Tent � Duration (Fire Retardant Certificate attached?) Wood Stove I 1
Siding:'#of Squares t, 0
Replacement windows: # Replacement doors: #
Roofing: #of Squares (❑) Remove existing* (max.2 layers) Insulation l l
�✓ Old Kings Highw ((ay/Historic Dist. )Replacing like for likei. Pool fencing T
,^_ J2 ,,),./- ti1�01,) (c.- — \ \ f t\)Lx_ c\C 1.t'i ,a `t°/ 7/_7
--(7 * -Vk
*The debris will be disposed of at: J(-rya 1./�► Location of,_c /‘. Yf
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 deniaho e n of my li se and for prosecution under M.G.L.Ch.268,Section 1.
CC Date: ti.�'1it,
Applicant's Signature: /� r� yy/�►�
a/ / ,Date: \ I 1as
Owners Signature(or attachment) t ,�j ( r�
Date: Y
Approved By: EMAIL ADDRESS:
Building Official(or de . ee
Zoning District:
Historical District: Yes No Flood Plain Zone: Yes No
Water Resource Protection District: Within 100 ft.of Wetl adds:
Yes No . Yes
The Commonwealth of Massachusetts
- I, Department of Industrial Accidents
� at11 1 Congress Street, Suite 100
=
f:_ <' Boston, MA 02114-2017
www.mass aov/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): \ ha, C w\-r"s-r--
Address: \t• kA ,,,p
City/State/Zip:�,�.1 ,Mp Phone #: - ')
Are you an employer?Check the appropriate box: Type of project(required):
I. 1 am a employer with 't'( employees(full and/or part-time).* 7. New construction
2.E I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling
any capacity.[No workers'comp. insurance required.]
9. E Demolition
' 3.Q I am a homeowner doing all work myself. [No workers'comp. insurance required.]t
10 E Building addition
4.C 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.❑Roof repairs
These sub-contractors have employees and have workers'comp. insurance.I E
.93
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14 �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 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: ik,(ki\`C.
Policy#or Self-ins.Lic. #: \ C'C 'S-6 0 W•) j r?6t% A Expiration Date: ( L\Z2,
Job Site Address:\Z-t 0%.n City/State/Zip: 1 c..crvvtAIV4RtA
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:
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
Division of Professional Licensure
Board of Building R
yeg}ulations and Standards
Constratthn� %tiprvisor
CS-075281 spires:03/12/2023
TODD J CANARA :r
10 ECHO RDA - x
WEST YARMOITH d 3
(),S'S,1:
Commissioner cig R. blEenaak.-
THE COMMONWEALTH OF MASSACHUSETTS Registration valid for individual use only before the
Office of Consumer Affairs&Business Regulation expiration date. If found return to:
HOME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation
TYPE:Indiv3duat 1000 Washington Street -Suite 710
Registration ;'Expiration Boston,MA 02118
159214 _04149t2024
TODD CANTARA
D/B/A CANTARA HOME SOUL.TIS
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TODD CANTARA 10 ECHO RD. � � / •
W.YARMODUTH,MA 02673 Undersecretary Not valid without signature
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