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HomeMy WebLinkAboutBLD-22-006732 BLD 120 s .- R /;a 542,3Q)..... 102-nce Use Only Y Ul 6/1d/ !Permit# Lif�� ©tT) C P 'Amount '?D #o CSEJ �, 4,oa.,:o^' Permit expires 180 days from I issue date 6 ' -- 2-- Ci 3 EXPRESS BUILDING PERMIT APPLICATI E G_E B V E D TOWN OF YARMOUTH Yarmouth Building Department MAY 20 2022 1146 Route 28 South Yaouth, MA 02664 BUILDING o rm DEPARTMENT (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: lC:\— Z 6 kL 4ti Yl , W J 1Q� �i ` ASSESSOR'S INFORMATION. ....... \\ Map: ` Parcel: OWNER: . kc S S Y. c- - C.G*" 16 - 35 NAME \ PRESENT ADDRES TTE # CONTRACTOR 1 dui Cr4,,, 0A--c. � a�`r` to s+ k..4,1 `041 i., s: . 61."'v , NAME MAILING ADDRESS 1 `�TEL.# ❑Residential aommercial Est. Cost of Construction$ 11 bb® Home Improvement Contractor Lie.# `C (Z't\ Construction Supervisor Lie.# CS -) 1 \ Workman's Compensation Insurance: (check one) 0 I am the homeowner ❑ I am the sole proprietor a4 have Worker's Compensation Insurance Insurance Company Name: U"\--Z Worker's Comp.Policy# •..1 cc S bCtIk.°)36cDiitsi WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares ?, 1 Replacement windows: # Replacement doors: # i ()ring: #of Squares ( )Remove existing* (max. 2 layers) Insulation Highway/Historic p •, _ Old Kin bgs Dist. ( )Replacing like for like Pool fencing /Sl'CtSI//62 I 0 e I-I e 6izath,n siat,r,ey(,obuildi'r4s) *The debris will be disposed of at: 1 C S'(,.,..b k.n... . \4-‘ er' SCAB 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 rr vocatio of my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: c6 C- Date: 1 i Owners Signature(or attachment) 2,. � Date: do rr Date: Approved By: 7. Date: Building Official(or designee EMAIL ADDRESS: Zoning District: Historical District: ❑ Yes 0 No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft. of Wetlands: 0 Yes 0 No 0 Yes 0 No The Commonwealth of Massachusetts 1..�-t� - ingm I Department of Industrial Accidents WE= 1 Congress Street, Suite 100 • _�• 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): \ ha, VC_Nr\\-0,s-r- Address: e � City/State/Zip:\ Le-l"wkb A,,. PIA Phone #: co Are you an employer?Check the appropriate box: Type of project(required): 1.Rram a employer with r'4 employees(full and/or part-time).* 7. E New construction 2.E 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. I am a homeowner doing all work myself. 9. Demolition y [No workers'comp. insurance required.]t 4.❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 7 Building addition ensure that all contractors either have workers'compensation insurance or are sole. 11.] Electrical repairs or additions proprietors with no employees. 12.Q Plumbing repairs or additions 5.[1.1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp. insurance.: 13.El Roof repairs 6.11 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Other S46t 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. I.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. Lic. #: C,e- 0 6 ? B b<2,61 q Expiration Date: (-2.\2,1 Job Site Address: t � ‘Ai� City/State/Zip: 1 C. 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: '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 Construh tAtSpp,rvisor CS-075281 cpires:03/12/2023 TODD J CANTARA ,* 10 ECHO RD1 "� " '' a WEST YARMt1JITI+ 3 <- l � mr L ff 1(*S 1:11)" Commissioner dgolt, 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: Office of Consumer Affairs and Business Regulation TYPE�:"lni�ividual. Registration Expiration 1000 Washington Street •Suite 710 159211 }: _04/0912024 Boston,MA 02118 TODD CANTARA D/B/A CANTARA HOME SeULTIONS t :. TODD CANTARA 10 ECHO RD. (r.ollL.�� W.YARMOUTH,MA 02673 Undersecretary Not valid without signature