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Home My WebLink AboutBLD-23-001620 BLD 105 / ,�,� fz.'7 1 �!1� Office Use Only �}1. G Permit � iig5 � t:V G' Amount 0.ab N ten-I19 .. • Permit expires 180 days from '-'. issue date RECEIVED EXPRESS BUILDING PERMIT APPLICATI TOWN OF YARMOUTH SEP 2 71022 Yarmouth Building Department 1146 Route 28 BUILDING DEPARTMENT By:_ South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 4 CONSTRUCTION ADDRESS: 13 i \ -' fon ,,i ;k`) a"i e,( 13t,-k--vv,„,,t\e, ASSESSOR'S INFORMATION: Map: Parcel: 3-0%)(41,--)5l D OWNER: �iAME +�i ` a—j- PRES T ADDRESS r� ` TEL. # `b CONTRACTOR: ( Ci/ � r`,, e, h `�. NA „ , `,\ \`u"' ,,A,L .# �U 3 tC1-7 1 i 1 - NAME MAILING ADDRESS 0 Residential ommercial Est.Cost of Construction$ 7j t 6616 t Home Improvement Contractor Lic.# Construction Supervisor Lie.# e ar) L b\ Workman's Compensation Insurance: (check one) ❑ I am the homeowner 0 I am the sole proprietor ❑}rave Worker's Compensation Insurance Insurance Company Name: ' Worker's Comp.Policy# CC'5t\o<60 3 UP-01 e ev k WORK TO BE PERFORMED n Tent 0 Duration (Fire Retardant Certificate attached?) Wood Stove 1 n Siding;- #of Squares t�,l Replacement doors: #Replacement windows: # Roofing: #of Squares (❑)Remove existing* (max.2 layers) Insulation I I Old Kings Highway/Historic Dist. (1) Replacing like for like Pool fencing ;v)vY15 — 1 vv 4rtv)c/- o1L 41 7/72 *The debris will be disposed of at: JC—r K3 1LA 1 lr.. \ 1-----`"-_ *cAinv---, 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 or ;.n of my li - se and for prosecution under M.G.L.Ch.268,Section 1. Date: ��Z7��Z Applicant's Signature: �fr' A'„ �/ � #ii ' ►•te: `\\'t-' ln' -�/ Owners Signature(or attachment) /�.�. i � , r / 7r _/�� „� Date: / pr Approved By: / "AIL ADDRESS: Building Official(or designee) Zoning District: Historical District: Yes No Flood Plain Zone: Yes No 0 ft.of Wetlands: Water Resource Protection District: Within 10 Yes No Yes No o The Commonwealth of Massachusetts 0=., Department of Industrial Accidents I Congress Street, Suite 100 0 lira•= Boston, MA 02114-2017 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): j ha,/ r,,s--„ Address: lb so City/State/Zip:\.,.1 P ;J'ie Phone #: �� (�� —k‘sk Are you an employer?Check the appropriate box: Type of project(required): I.Rram a employer with (4 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. ❑ Remodeling any capacity.[No workers'comp.insurance required.] ' 3. I am a homeowner doing all work myself. 9. ._ Demolition C y [No workers'comp. insurance required.] 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 1 1.❑ Electrical repairs or additions proprietors with no employees. - 12.❑Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.El 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.eether 5k. 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 ant 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.Lic. #: 's 0 Thk 7' t 1O1% A Expiration Date: (Z, Job Site Address: t W e.,n City/State/Zip: 1st 4 bv- 4 bC� 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$250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cer ' he pains and penalties of perjury that the information provided above is true'and correct. Signature: Date: Phone#: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License# Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: Commonwealth of Massachusetts Division of Professional Licensure • Beard of Building Regulations and Standards Const,rott$r 4prvisor CS-075281 =- 6(pires:03/12/2023 TODD J CANTARA 10 ECHO RDA 4 WEST YARM4/T14. 02, 3 10/Si;1:10"‘` Commissioner chat 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:In"aividual 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 HO44E SOT `Tloil15 TODD CANTARA 10 ECHO RD. W.YARMOUTH,MA 026 , Undersecretary Not valid without signature