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Home My WebLink AboutBLD-19-002906 Office Use Only 9 1 .Y R �. O Permit# I O "mestisy,fit H I Amount s— i' %):1;.......,,(.7g Permit expires 180 days from RECEIVED EXPRESS BUILDING PERMIT APPLICATI 1 110V 13 2018 TOWN OF YARMOUTH Yarmouth Building Department BU ly�t.El vn rrr��c�,T 1146 Route 28 BY: . __. .__ SLL SouttyYarmouth, MA 02664 (508 7- 98-223111Ext. 1261' • CONSTRUCTION ADDRESS: ,7-2� `Z� `\ \ `YCQkfe-9. kei Wd\.1 {c3 (04 ASSESSOR'S INFORMATION: 1� 1\ 1 Map: Parcel: I OWNER: V�.�'`�-^ 1 V"G C � (o ktto) C&rC4\ ISOI j tar' Si l b NAME In — PRESENT ADDRESS J TEL. # CONTRACTOR: \ ��:. � e- c ec \C) \ tJ 4,p-F"... s-6-6-3 C(is-1 NAME MAILING ADDRESS ❑Residential CS/Commercci-all� Est Cost of Construction$ ` bbO -� Home Improvement Contractor Lic.# `CSS \ Construction Supervisor Lic.# q CSS)SZ.R k Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor Q.Yhave Worker's Compensation Insurance y�r� * +� �/'�j� Insurance Company Name l� Worker's Comp.Policy# S�t c\lc )S -. )19 a WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares kt, Replacement windows:# Replacement doors: # s Roofing: #of Squares ( )Remove a sting* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( eplacing like for like Pool fencing "The debris will be disposed of at d'Gr - a .. t `- UNttlOr _ L, ation of Facility I declare under penalties of perjury that the statements herein contained a 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 rev. . awn • license and for r tion under M.G.L.Ch.268,Section 1. � 1 ( Applicant's Signature: - Date: t t I �J1 l � Owners Signature(or attachment Date: l\C Art, / ` Approved By: / / Date: // /05 :.rig r.'icial(.r designee) E : eaRESS: Zoning District: Historical District: 0 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 ';J !I r _ / Department oflndustrialAccidents v ==e_=4 1 Congress Street, Suite 100 = r= Boston, MA 02114-2017 C.,;4 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): 7..0& . c Address: \bLtb 'c\,. City/State/Zip:\r i , __iyv Jj 1\./\ Phone #: SO -- (pl '`\S\ Are you an employer?Check the appropriate box: Type of project(required): 1.01 am a employer with employees(full and/or part-time).* 7. ❑New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.[No workers'comp.insurance required.] 3. I am a homeowner doingall work myself. t 9. ❑ Demolition ❑ ys [No workers'comp.insurance required.] 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 sole 11.0 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 These sub-contractors have employees and have workers'comp.insurance.t 13.❑Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.��er 5 t k .<� 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 subcontractors 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: 11\1\/\.\ ,.Policy#or Self-ins.- Lic.#: \AC_C till C•357) 1*--, 33657,017 jExpiration Date: (Z hAcil Job Site Address: Gicl Jr,,, Gcs, , City/State/Zip: 0 c Attach a copy of the workers' compensation policy declaration page(showing the policy number and expirationdate). 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 u a _ - .ains and penalties of perjury that the information provided a'ove i true and correct Signature: —�jj Date: 1 \\ 1 Phone#: c a 3CC) -l\ 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#: • #.) . Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in ajoint enterprise, and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership, association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states "Neither the commonwealth nor any of its political subdivisions shall enter into any contact for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contacting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and,if necessary, supply sub-contractor(s)name(s), address(es) and phone number(s) along with their certificate(s)of insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary) and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 r ' Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 02-23-15 www.mass.gov/dia At Massachusetts Department of Public Safety �• Board of Building Regulations and Standards ;' • License: CS-075281 -•- Construction Supervisor F TODD J CANTARA 10 ECHO RD r b2 . • � ' WEST YARMOUTH MA 02073 - • AFL '.tr !acs- `— Expiration: • 'Commissioner 03/12/2019 • eh%anionnmee/(A oto liamerdettr h Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE,IndMdual ffeaistratlon Expiration 15921174 +; 04/09/2020 TODD CANTARA D/B/A CANTARA HOME SOULTIONS TODD CANTARA 10 ECHO RD. U —"•'�6 W.YARMOUTH,MA 02673" Undersecretary Registration valid for individual use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation One Ashburton Place-Suite 1301 Boston,MA 02108 • Not valid without signature • 4. • /"1 TODDJCA•01 'ACOR0' • a,ss"--1,,.,.,.,1 .1/4.---- CERTIFICATE OF LIABILITY INSURANCE 0El2TJ2018 THIS CERTIFICATE IS ISSUED AS A MATTER OP INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES •BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED ' REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT; If the certificate holder Is an ADDITIONAL INSURED,the polley(Iss)must haw ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WANED, subject to the tonne end conditions of the policy,certain polleln may require an endorsement, A statement on this certificate don not confer rights to the certificate holder In lieu of such endorsement(s). PRCOUCU _Went 2374trray Insurance Agency,Ins. Pa,'41..Ego in,No, South Dinh,MA 02680 - A Ae. . INmlt AfFORE$O CdyfAoa NAIL. • ' ,,sincqji:MaIn Street AmerIca Assurance Company 29939 MEMO scAssociatedEmoloyenlnsuranceComoany 11104 Todd J.Cantata Swot dim Cantata Home Solutions - - - 10 Echo Road rlRJ ' __ WestYarntouth,MA 02673 INSURER Er MAURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HLAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FORME POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE AMY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT'MALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.UMR'S SHOWN MAY HAVE BEEN REDUCED�pryBY�PAID CLAIMS. NM T'/re OFIMelIRMa ADL.BURR Ip irralP kDoX•V�iYI MT* WO Mel POLICY OM nW • A CON.nciacvist .warm m•CHOCL _RL6._ 1 1,000,000 MAXASMAbe ❑OCCUR A1PX6929N Oa/0312011 06/03/2019 FRD LM4E> e,ecormew t MED IMP Nyco*mood f 10.000 • — penceAL eAOYPLRJRY 't 1,000,000 2000000wn AP SPER PCE rL►FeAuE iLoc • PRODUCTS •COMP/OR AGO $ 2,000.000 OTHER NO!OMOZ RABBET SIAiumEEo SINGLE LAR $ R — ANY N.UUWO —warn SCOE?N.URY lrne..mI O _ — NNNRErt,ppO�snot( — Of AMY NARY(�esec+n.A , —AUT03 ONLY —Mang P eply,q ! I UMBRA IMO OCCUR • EACH OCCURRENCE e LEMS MAN CLAa14NADE 'DEC - I Rt:TBYIIDNI AGGREGATE 5 6 ROWERS MO OERL,ATION Rm, iSTA"NFI IR ANY PROMILROWPARTIEREXECLITNE l—,fn WCC.500 501Ta0s401$A 81241201/ 06(24/2019 ELFUHACCIENT $ 100,000 grariorinmin EXCLUDED? NIA ��TTA{ EL DISEASE.EA EMPLOYEE $ 100,000 pESCMPTION OOPOPERATIONS WON EL OISEASE•POLICY.MT a • 500400 • OEAOIORION OP OPERATIONS ILOCAiioNa/VENOM WON)tet,ARENS RerNSA IMM""swy B.esther fawn Spin I.waive) • CERTIFICATE HOLDER • _CANCELLATION • • SHOULD All?OF THE ABOVE moms POLICIES BE CANCELLED BEFORE • NanryMTHE EXPIRATION DATE THEREOF, NOTICE MILL BE DELIVERED IN SaNancy Higglggins ins ACCORDANCE WITH THE POLICY PROVISIONS. DrifSouth Yeimoutit,MA 02661 NEFRpE1RA7M • • • ACORD 23(2018103) 0 19 06201 5 ACORD CORPORATION. All rights reserves a The ACORD name and logo ere registered marks of ACORD