Loading...
HomeMy WebLinkAboutBLD-23-002965 014,t ._. i t j3 6 .,. rECEIVED �� Office Use Only 01'Y`�R n `�p ..,.p_ Permit#C ��� X. 00 1,9 NOV 29 2Q221 .Amount C7 y NATTA M [it L.,- F,. <, ,a. :;d - Permit expires 180 days from ` II�I T issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: la `'"^5( .2-c-- "" L`^ c l ASSESSOR'S INFORMATION: Map: Parcel: OWNER: 3\44.1x\ L?.& . L15_ k l.1c-Sy‘ c \ ak,CZa,( o I)'1 6% C NAME Cyr I PRESENT -DRESS\�, k+� I TEL. # i 7 CONTRACTOR Q ram-. '�f,(� � �� `�6/.---t NAME MAILING ADDRESS TEL.# ❑Residential ❑Commercial Est.Cost of Construction$ 166 0 Home Improvement Contractor Lic.# \` `;7.\ t Construction Supervisor Lic.# n 9 s-ZA t Workman's Compensation Insurance: (check one) � 0 I am the homeowner \ ^❑ I am the sole proprietor [lkhave Worker's Compensation Insurance �\y Insurance Company Name: I`W, Worker's Comp.Policy# `..k;�, (3 s' (1 2,462Za WORK TO BE PERFORMED Tent 7 Duration (Fire Retardant Certificate attached?) Wood Stove El Siding: #of Squares Replacement windows: # Replacement doors: # l ?Pr Roofing: #of Squares (❑)Remove existing*(max.2 layers) Insulation L I I I Old Kings Highway/Historic Dist. ID Replacing like for like Pool fencing I "The debris will be disposed of at: Nvd\A ��r^`^�Ck-Z C.-' 9N••••4'‘.6 V\,../ Location of Facility I declare under penalties of perjury that c st: meets 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 or revoc. - •y licens. •a for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: ('' °AI Owners:gnature(o attach at 'A "Pr Date: Nov 29 2022 eA;!7 3�/z// Z Approved By L,;.�r�i Date: {,--$ ' • _ 74'''�''" (or designee) EMAIL ADDRESS: Zoning District: Historical District: C+ Yes ❑ No Flood Plain Zone: E Yes C No Water Resource Protection District: Within 100 ft.of Wetlands: r1 Yes 1 No vl Yes n No __ • The Commonwealth of Massachusetts 1 "—0: - 1, Department oflndustrialAccidents k_;el= 1 Congress Street, Suite 100 __ 4• Boston, MA 02114-2017 '~ www.mass.gov/dia«Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): \6& _ )"?-4-0-- Address: 1C. €A,.,--) '&- City/State/Zip: \.,1 ,lts-c-, ,D\,„, , I ` NA, Phone#: ?8 3 (;, >-( 1 Are you an employer?Check the appropriate box: Type of project(required): l.E0yet n a employer with I- employees(full and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. ['lemodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.12I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 ❑Building addition 4.❑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.❑Electrical repairs or additions proprietors with no employees. 12.['Plumbing repairs or additions 5.❑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.t 6.❑we are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§I(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: Policy#or Self-ins.Lie.#: 10 ,C5 6 Q\7 ZO 2,uk Expiration Date: i'd ZZ Job Site Address: (0 .aCC--- .-a City/State/Zip: `�t r-� ( t114 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 certify the pains and penalties of perjury that the information provided above is true and correct Signature: — Date: t l L ( ZZ. 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 B6ard of Building Regulations and Standards Cons�itisor '" .1 CS-075281 - spires:03/12/2023 TODD J CANTARA � 10 ECHO RD.- , WEST YARMWTH MA 0-2673 1 Commissioner (1421. K. btenack, THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer HOME Affairs&Business Re IMPROVEMENT CONTRACTOR lation R istra ndiViidual 15— 1.on k iration TODD CANTARA 4 }©9/2024 D/B/A CANTARA HOME titt ? TODD CANTARA 10 ECHO RD. <W. YARMOUTH, ' MA 02673„ - yell -cGr>aC Undersecretary