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Home My WebLink AboutBLD-19-2907 r•:see Use Only zOpt"' - • .e 141/0-19‘-°6 g 912 Amount ff., Gj :`sloe dare t EXPRESS BUILDING PERMIT APPLICATI b)\ NOV 13 2018 TOWN OF YARMOUTH Yarmouth Building Department euy" j E prink 1.27T 1146 Route 28 By v'�—;�ILJ� 1 South Yarmouth,MA 02664 (508) 398-2231 Ext. 1261 • tJ�\ CONSTRUCTION ADDRESS: 2, \� 1 o \ O.C`CP s\ ASSESSOR'S INFORMATION: Map: Parcel: OWNER MV".0.‘C V v Com/\ .). ADDRESS�2 ,C.\�S 11 C4JSO/3(47,-5c\\b CONTRACTOR AIL C tT \p MAILING th ( W Y r % c o�3 x-1'1\S1 NA❑Residential NlCommercial Est Cost of Construction$ („,( ) h b Home Improvement Contractor Lic.# 1 S' z,l( Construction Supervisor Lic.# CS1'l Z p t Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor cZave Worker's Compensation Insurance t� Insurance Company Name: %\ c. Worker's Comp.Policy# W C�,� S2V6't\--i& 17 WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Lo Replacement windows:# Replacement doors: # Roofing: #of Squares ( )Remove [sting*(max.2 layers) Insulation Old Kings Highway/Historic Dist. ( Replacing like for like Pool fencing LI\*The debris will be disposed of at: _mi.iia, Cr ¶A V 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 revocation f license and for prosecution under M.G.L.Ch 268,Section 1. Applicant's Signature: ' Date: 13 I.I. Owners Signature(or attachment) / 1 Date: ' Approved By: �� - Date: / - •mc tial(or designee) Ea". ADDRESS: • 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 • J • The Commonwealth of Massachusetts "s=r = Department oflndustrialAccidents ==dl= 1 1 Congress Street, Suite 100 •_1 _gt Boston, MA 02119-2017 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): i CJJ l Address: \d \ \.4 . City/State/Zip: \.J t1/4"\.c,--r-4,iQu Phone#: ISC/8 6-2 - lk-S1 Are you an employer?Check the appropriate box: Type of project(required): 1. A 1�m a employer with 2 employees(full and/or part-time).* 7. 0 New construction 2.0 1 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 doingall workmyself. t 9. Demolition❑ ❑ [No workers'comp.insurance required.] • 10 ❑ Building addition 4.❑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 11.0 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.❑ of repairs These sub-contractors have employees and have workers'comp.insurance.: `y. �1 6.0 We are a corporation and its officers have exercised their right of exemption per MGI..c. 14.Lr+�dwmer 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. lithe 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: IV Policy#or Self-ins.Lic.#:,i4(`r Zb A7 ln c 7)`)A. Expiration Date: 1 z4 wit; Job Site Address: 3 k \ 6c-e chis Gs-4e , City/State/Zipn. " of Wl slll Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiratio ate). 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 certir.- • •• the pains and penalties of perjury that the information providedabove is true and correct Signature: Date: \\ \` S 1 lA Phone#: So% 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 a joint 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 contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting 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 retuned 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 burn 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 t� Massachusetts Department of Public Safety : Board of Building Regulations and Standards , License: CS-075281 , Construction Supervisor TODD J CANTARA 10 ECHO RD ,; r M WEST YARMOUTH MA 502673` /3: a{2 Expiration: Commissio er 03• /12/2019 ' • Ed?6 1(Hrnmontfirce l olb ihwaehaefiJ Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE;IndMduai Registration gzpiratlon 159211- > 04/09/2020 TODD CANTARA • - D/B/ACANTARA'HOME SOULTIONS 10 ERDARA 10 ECHO RD. 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 -,, • ...e1 TODOJCA-01 THORNE 'AGGRO' DATE WEVODN17Y) ,` CERTIFICATE OF LIABILITY INSURANCE 08!27/201e THIS CERTIFICATE IS ISSUED ASA MATTER OF 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 Certlnea%holder Is an ADDITIONAL INSURED,the pollcypes)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the Tema and conditions of the policy,certain pollstas may require an endorsement. A statement on this certificate does not confer rights to the certificate holder M lieu of such endonenam(s). PRODUCER Aira Rogers a Cray Insurance Agency,Inc. • a 434 e eeh Mick South uDennis, nnis,MA UMW l' TI RfsURERGINTAw,No eQYERAOE RAIL•e INSURER A:Main Street America Assurance Company 29939 INSURED JNNmzea+AssoelatedEmployers Insurance Company 11104 Todd J.Camara -e C• dba Cantata Home Solutions 10 Echo Rad awmeggi West Yarmouth,MA 02673 „MUM I Mama P, COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR DM POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HERON IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OP SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. eat Ma.WER R rIrn POLlerall Lilt TiPi Of IN:URARCf IMO LINO POLICY Rumen R OIYYYYI IYWDNYYYYI ULM • A coeunMLOENEIIN.tumor EACHOccue Ntf_____i 1,000,006 OLAJMSMAOC OCCUR MrE RENRD I MPKSOMN 0610L2076 06102@019 $AFwsP�9E.amnAnvi f — MED ret*mone erRml I 10.000 - PEIISCRALa ACV HURT '= 1,000,000 �A Tf APPyEI f GENERAL AGGREGATE f 2,000,000e CCyv L�I U • PROttcTS•wMnaPAGO f 2.000.000 dn+ERC I UTOmOsta LMAMRIIS $01241^NED rail LIAR $ —AWAUIO aoeaY KMRY(Pre,nmi f — �OpzNI,nIfEp OILY _IQgttm yNEp eBCCOOIpLEYflAIRY OW want 5 ZS ONLY —MOSSO(.'O W.lrign E $ f UMBRELLA Lull OCCUR EACH OCCURRENCE $ ^ INCrn MS CLAW-WM • AGGREGATE S DED I I RETENTION: ' f 8 AND nuoWORMUrra UABCOmPERI'LJTY I BTARnnoou I I E? wePROMETORR+ARINERRI(EClnryau_.1 j WCC•800.501750S201$A 06/241201$ 06124/2019 EL EACH ACCICENT $ 100,000 Inv ExCLUown N/A 1f EL DISEASE-EA EMPLOYEE II 100,000 oESCRI nON OAOPERATIONSNM EL MEM-POLICY LMT f 500,000 DEICIBPNON OP OPENAT ONS I LOCATIONS NEMCLas IACORD 15%Md*SS RNM4 SAW%imp he NSW seen RMS Y nail • CERTIFlCATE HOLDER SANCEU.ATION • SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Nancy HlgglM THE EXPMATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Nancy Higgif sane ACCORDANCE WITH THE POLICY PROVISIONS. DrifSouth Yarmouth,MA 02664 REPRUDITATN! ACORD 25(2015103) 01980.2015 ACORD CORPORATION. All tights reserved C The ACORD name and logo ere registered marks of ACORD