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Home My WebLink AboutBLD-22-007163 , p 4 I p //z/Zz__ ., Office Use Only �'4 `fit Permit# 0367 O1 H Amount s O.60 "`'" ..-rid` Permit expires 180 days from r ;issue date EXPRESS BUILDING PERMIT APPLICATI , _ � 1 TOWN OF YARMOUTH '` � E I V E D Yarmouth Building Department 1146 Route 28 JUN 10 2022 South Yarmouth, MA 02664 (508)398-2231 Ext. 1261 BUILDING DEPARTMENT By: CONSTRUCTION ADDRESS: �� \)oCff1(. ,. p C--• ASSESSOR'S INFORMATION: Map: Parcel: —it\ 75 5- Z i 31 OWNER: S v`c'JeN y,A rt,Ascz Vr'1 �( Or 8 t,,iC` MP\ NAME PRESENT ADDRESS t , TEL. # CONTRACTOR:`7S t1' Z- ,v"s'` (It� ' ,, ) .N. w rlic..,— ,w \Atr`.V"! v NAME ,.ING ADDRESS TEL.# I E7 e lential CI Commercial Est.Cost of Construction$ 5 0-66 50E _3L17-1151 Home Improvement Contractor Lie.# 1 C` Construction Supervisor Lic.# OiSr)S Cit8\ Workman's Compensation Insurance: (check one) ❑ I am the homeowner ❑ I am the sole proprietor ❑ I have Worker's Compensation Insurance Insurance Company Name: i`N Worker's Comp.Policy# \ ( l ) CtN7 a. WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares ) Replacement windows:# Replacement doors: # Roofing: #of Squares ( )Remove existing*(max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: Location of Facility I declare under penalties of perjurthat 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 viacation o license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: < Date: Cct `r It_ Owners Signature(or attachment) " Date: ., ni,___—) fir Approved By: l ° ® �3 Date: `7,"0—__ Building Official(or n) EMAIL ADDRESS: Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: L Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: ❑ Yes 4 _1 No ❑ Yes ❑ No Commonwealth of Massachusetts g Division of Professional Licensure Bdard of Building Regulations and Standards Constr reit6Aipervisor CS-075281 7 I(pires:03/12/2023 TODD J CANT:ARA r 10 ECHO RD1 WEST YARMOjJTH ' 3 r` Commissioner clog . `lI i_140_ 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'1nir iwdual- Office of Consumer Affairs and Business Regulation Registration ,x Expiration 1000 Washington Street -Suite 710 159211 _. 04109/2024 Boston,MA 02118 TODD CANTARA D/B/A CANTARA HOME ssOULTIOI4S 10 ECHO RDAif W.YARMOUTH,MA 0267 • Undersecretary Not valid without signature t The Commonwealth of Massachusetts Department of Industrial Accidents _= 1 Congress Street, Suite 100"—' Boston, MA 02114-2017 �•' www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/PIumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): \(N� �^ Address: V) City/State/Zip: W `` C-rti ;. ' ,roAk Phone#: StS 3 L--'— Are you an employer?Check the appropriate box: Type of project(required): t.El•fram a employer with ✓ employees(full and/or part-time).* 7. 0 New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in any capacity.[No workers'comp.insurance required.] 8. remodeling 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑Demolition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 []Building addition ensure that all contractors either have workers'compensation insurance or are sol proprietors with no employees. 11.0 Electrical repairs or additions 5.0I am a general contractor and I have hired the sub-contractors listed on the attached sheet 12.0 Plumbing repairs or additions These sub-contractors have employees and have workers'comp.insurance? 13. Roof repairs 6.0 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. tContractors 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.Lic.#: ('t,5"" F�- s1 0 (II Expiration Date; t� Z,t, Job Site Address: City/State/Zip: 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 � and penalties of perjury that the information provided above is true and correct Signature: �- Phone#: Date: 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): I.Board of'Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: