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EXPRESS BUILDING PERMIT APPLICATIO L V
TOWN OF YARMOUTH SEP o 7 2022
Yarmouth Building Department
1146 Route 28
BUILDING DEPART ENT
South Yarmouth, MA 02664 By
(508) 398-2231 Ext. 1261 6\ c')
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CONSTRUCTION ADDRESS: V � �-�
ASSESSOR'S INFORMATION:
�, Map: r Parcel: 450%3�c �. t DOWNER: \ .. y atilt, 0.� Cj\'N PRES T ADDRESS)" (_A v-c k' 41' # n(N'
NAME J L
CONTRACTOR: t, c+i 4•' .1� ,ire. (() ((,C.�„p \(. WJ, kkis ,,Q - L �1t 3(c)-7 1 l 1
NAME MAILING ADDRESS TEL.#
❑Residential ommercial Est. Cost of Construction$ 6 D 06
Home Improvement Contractor Lic.# ` t\\ Construction Supervisor Lic.# t„5'1ct_
Workman's Compensation Insurance: (check one)
0 I am the homeowner 0 I am the sole proprietor ,k4iave Worker's Compensation Insurance
Insurance Company Name: Worker's Comp.Policy# W+,c,' l' `73 "7lO1?j Pam,
WORK TO BE PERFORMED
Tent Li Duration (Fire Retardant Certificate attached?) Wood Stove
Siding: #of Squares 1 Replacement windows: # Replacement doors: #
Roofing: #of Squares (❑)Remove existing* (max.2 layers) Insulation L I
Old Kings Highway/Historic Dist. )Replacing like for like Pool fencing
Ml14 0 A)n -VI In.) Ls - 1 ` 11)!� :;1�-- ,l,-t , /4--i '
*The debris will be disposed of at: C-r\rsrvn t r' .y S
Location of Facility *1:".-"\-61r.----'
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 se and for prosecution under M.G.L.Ch.268,Section 1.
Applicant's Signature:
Date:
Owners Signature(or attachment) /L-' Q/�� _Date: t
Approved By: 6 Date:
Building Official,(or deli e) 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
Department of Industrial Accidents
IN mow
1 Congress Street, Suite 100
•— Boston, MA 02114-2017
e.
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
ADDIicant Information
Please Print Legibly
Name (Business/Organization/Individual): ,ha, \
CNV�,'Y GnST�
Address: •
City/State/Zip: tr`C'Crvot,. 1 J'iA Phone #: 5-ota - tom') -k\ck
Are you an employer?Check the appropriate box:
Type of project(required):
1.privam 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 wor.<ing for me in
any capacity.(No workers'comp.insurance required.] 8. Remodeling❑
3.E I am a homeowner doing all work myself. [No workers'comp, insurance required.] 9 ❑ Demolition
4.E I am a homeowner and will be hiring contractors to conduct all work on m property.Y
I will 10 [] Building addition
ensure that all contractors either have workers'compensation insurance or are sole
proprietors with no employees. 11.E Electrical repairs or additions
5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 12.❑Plumbing repairs or additions
These sub-contractors have employees and have workers'comp. insurance.t 1 •El Roof repairs
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.[ether 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 showirg 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: k
Policy#or Self-ins. Lic. #: WC„, 'SI 2,61 q Expiration Date:
Job Site Address:/11-tv... V(eN.n City/State/Zip: lc,c'Gvp b<
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: \-7� Z
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#:
Commonwealth of Massachusetts
® Division of Professional Licensure
Board of Building Regulations and Standards
Const*iliio YY tjpq,rvisor
CS-075281 .;y E,ipires:03/12/2023
TODD J CANTARA 7, ;,
10 ECHO RDs , 1" M•
WEST YARMOUTI4 \1; 3 O
Q
'/ 4 t` b3
Commissioner caU i,. 8` ,c .,
THE COMMONWEALTH OF MASSACHUSETTS
Office of Consumer Affairs&Business Regulation Registration valid for individual use only before the
HOME IMPROVEMENT CONTRACTOR expiration date. If found return to:
TYPE 'Iri8ividual_ Office of Consumer Affairs and Business Regulation
Registralloft V 1Ekjilratiort 1000 Washington Street •Suite 710
158211` , p4/09/2024 Boston,MA 02118
TODD CANTARA `a1_,t7 s4
D/B/A CANTARA HOME ' ,,
Y S
TODD CANTARA 'r /J
10 ECHO RD. } ` ��,�,'"'"(4 '/� '.4.
W.YARMOUTH,MA 02673? " ,.` `
-`11- Undersecretary Not valid without signature
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