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HomeMy WebLinkAboutBLD-23-001917 BLD 113 Cwd ILA 01 JZI Z Office Use Only °f RR � O; Nano` e,,_4131g1 � At, ! � O - �� Amount q[), Permit expires 180 days from =" .= issue date EXPRESS BUILDING PERMIT APPLICAT �� 3 �Od TOWN OF YARMOUTH tl ' ' " ° 'i D Yarmouth Building Department I 1146 Route 28 OCT 112022 1 South Yarmouth, MA 02664 w . (508) 398-2231 Ext. 1261 U DlNG ARTMEiJT CONSTRUCTION ADDRESS: G 6—3O LI ASSESSOR'S INFORMATION: Map: Parcel: Tat)(4.1.7.351 fl OWNER: . y JA 0.".� C C1b J PRES T ADDRESS)" Ci cc EL.# 1 0 CONTRACTOR: c�/c� fL Ar l `ea,-,0 1t 4 , A- \� �4b,,,A,L cbI) 31n� --1 LC ACE MAILING ADDRESS TEL.# xx 0 Residential ommercial Est. Cost of Construction$ ` (00 U(), ;� Home Improvement Contractor Lic.# r L\\ Construction Supervisor Lic.# CS')cL Workman's Compensation Insurance: (check one) 0 1 am the homeowner ❑ I am the sole proprietor 0.-Yftave Worker's Compensation Insurance Insurance Company Name: 1:1f Worker's Comp.Policy# ((*mug:,,'7 3 ti01, WORK TO BE PERFORMED Tent El Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares i L., Replacement windows: # Replacement doors: # Roofing: #of Squares (El)Remove existing* (max.2 layers) Insulation n 1tOld Kings Highway/Historic Dist. )Replacing like for like Pool fencing — i'Mv c �"✓ ;v1vrlj 1./..i - 1 ' ,,-r1v)C_ C— ,mot ,a 4/ 7/7_, *The debris will be disposed of at: ('JC-r\,.,.,0 t A 1 l--, �f"-. ',,. C *r./Albr' ,_, 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 se and for prosecution under M.G.L.Ch.268,Section 1.Applicant's Signature: Date: 0 \1" Owners Signature(or attachment) te: io\\ ----3Approved By: Date: �© Building Official(orsig EMAIL ADDRES 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 't a =-= Department of Industrial Accidents rawjei1= 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.go v/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): 1 ha Czxv-N. Address: \te City/State/Zip:i,.l �� rr,('�.,Lb�..` + PIA I A Phone #: oz -k\s"k Are you an employer?Check the appropriate box: Type of project(required): l.Rram a employer with e'( employees(full and/or part-time).* 7. E New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 3. I am a homeowner doing all work myself. 9. C Demolition ❑ y [No workers'comp. insurance required.]` 4.❑ ProPTA' I am a homeowner and will be hiring contractors to conduct all work on myproperty. I will 10 [l Building addition 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.; 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. r 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: it\p,-t, Policy#or Self-ins. Lic. #: CS, 0.Thk 3 ?,bt Expiration Date: �Z. Job Site Address:\tom' �(e,.. City/State/Zip: Ic.c-TntI b(d 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: ld 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�� r��l and Standards ConstrN)tekto YS p rvisor CS-075281 ti% 4 4 spires:03/12/2023 TODD J CANTARA 10 ECHO RDA WEST YARMO31T14 b 3 Commissioner c 'aa THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation Registration valid for individual use only before the HOME 1MPROVENIENT CONTRACTOR expiration date. If found return to: TYPE"inaividual: Office of Consumer Affairs and Business Regulation Registration = Expiration 1000 Washington Street -Suite 710 159211 `:04/09/2024 Boston,MA 02118 TODD CANTARA D/B/A CANTARA HOME SOU l` 4S TODD CANTARA f 10 ECHO RD. +:' a•l 0k W.YARMOUTH,MA 026 :, Undersecretary Not valid without signature g