The URL can be used to link to this page

Home My WebLink AboutBLD-19-004082 i Office Use Only • Of•YHR g v +, •' G'! _ Permit# -401r •$p , •• il_4 y Amount VD N `--„_i6),~ ....0.$/"...,' ._. . - Permit expires 180 days from issue date S th-4C7—allo a-- RECEIVED" ' EXPRESS BUILDING PERMIT APPLICATI TOWN OF YARMOUTH JAN 1 1 2019 Yarmouth Building Department �,�,,� 1146 Route 28 surer 1 T BY: South Yarmouth, MA 02664 (` (508) 398-2231 Ext. 1261 1CONSTRUCTIONADDRESS: (12 t44 t `C, Z� y._ \�rk (6tcs \d\ 1tB) ASSESSOR'S INFORMATION: • Map: Parcel: OWNER: \CA\i aS \A ,. Con.�?oS (0-2– tea 5 G'c t,4 Wsv.02,- 5t0) NAME \ J PRESENT ADDRESS • �j.\dTEL. # _ CONTRACTOR: `NAME E4S� o II MAILING ADDRESS I6 \� � � 3(��.-c ts ❑Residential mmercial Est Cost of Construction$ 11S1:41) Home Improvement Contractor Lie.# ('S`\Z\\ Construction Supervisor Lie.# CS d?S-Z' 1l Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor Q..dave Worker's Compensation Insurance Insurance Company Name: Pt Mt Worker's Comp.Policy# W C C2SttSSIZI e (�octO\'j A WORK TO BE PERFORMED Tent _ Duration f / (Fiie Retardant Certificate attached?) Wood Stove Siding: of Squares 7 6 Replaceme t windows:# Replacement doors: # Roofs ,: #of Squares ( )Rem ye existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing "The debris will be disposed of at 'Ls_ • I t.-�S ocation of Facility I declare under penalties of p-' 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 , vo of m ' - - and for prosecution under M.G.L.Ch.268,Section I. Applicant's Signature: _ - Date: I ( 1 t VI Owners Signature(or attachment) 197, '/AK/ Date: l/4 /5 Approved By: J��' Date: /9—/0•—/p' B • . g/%cial(or designee) / MAIL 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 , ✓' The Commonwealth of Massachusetts .J 1---ar, f Department oflndustrialAccidents ii TAmal- ss 1 Congress Street, Suite 100 •• • �Ff_ i if Boston, MA 02114-2017 %ELF www.mass.gov/dia • Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information 4 Cts Please Print Legibly Name (Business/Organization/Individual): Address: IO ,,,b ?, City/State/Zip: L.Ic`-\a r tt l Q Phone #: ca ( ? --k k Cl Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with 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 doing all work t 9. ❑ Demolition ❑ myself[No workers'camp.insurance required.] 10 0 Building addition 4.0I 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.❑ Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.lairm a general contractor and I have hired the sub-contractors listed on the attached sheet 13.E Roof repair These sub-contractors have employees and have workers'comp.insurance.* 6.0 We are acorporation and its officers have exercised their right of exemption per MGL c. 14.l]Ather 1/a,,.) 152,§1(4),and we have no employees. [No workers'comp.insurance required.] 'Arty 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: k 1 ,;t ` Policy#or Self-ins.Lic.#: WCCi C)La Oki N:::$451OY7it\ Expiration Date: \4ZDI;�I Job Site Address: 4 e-- (---- "N.i-...— tze.Z, City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). 1_6" 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 c ' r'he pains and penalties of perjury that the information provided above is true and correct. Signature: Date: i (41 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/1'own 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,§250(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, §250(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 sten 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 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 • .............", TODDJCA.O1 THORNE •AtC..--- CERTIFICATE OF LIABILITY INSURANCE 08127/o e" THIS CERTIFICATE IS ISSUED ASA MATTER OF.INFORMATION °RIVARD CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDERTWS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND. EXTEND OR ALTER THE COVERAGE AFFORDED BY DIE 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: E the certificate holder Is an ADDITIONAL INSURED,the poilcyQes)must have ADOmONAL INSURED provisions or be endorsed. If SUBROGATION IS WANED, subset to the coma and conditions of the policy,urialn poncho may require en endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PROOUCER ISMCICT R Gray rom MaueeAping,Inc. �lircNee Fite 134 South DemnN,MA O26e0 • INSURERIeIWORMS COMM NAOS INSURER A:Main Street America Assurance Company 29939 NaINSD SWIM s:Associated Employers Insurance Company 11104 Todd J.Canters emsnlR e e ea Canters Home Solutions - - - 10 Echo Road R°c a+ • West Yarmouth,MA 02173 NNW=E, - INSURER P: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OP INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE 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 HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REPDDpUNJ�CCEED�iBPY PAID CLAIMS IHR Ins ormaut cs AWL we PoUcyRUeea n1EAT1GYt'YYm iYW W tam A corium&canvas mum' JV X412n a. s 1,000,000 CaAalawee D OCCUR MPKS929N 06/03/2013 06/03/2019 P°R"*"�iataga , e MEOIMP(Am one oimonl s 10.000 PERSCNALANN PUURY $ 1,000,000 ,94 suicve,OA�E AFB S! 2,000,000 _�JIII►AOOR II ILL�JI GENERAL f PROCUC73-CCMPpPAoO t 2,000,000 OTHER e IWIaMosaatYenrn a LW $ _ pNpW�MIY1AEUpro _�p�Pq�LEp- sooty WURY(Pr mewl 3 VOb ONLr Q1 BODILY WAY nor Idem s ,—2t7diaar _A"9=7 Mar"" s I _ NLBRELLAw LOCCUR • EACH OCCURRENCE e _ MISS MS r CIAMSMAD€ • t AGGREGATE S On I I RETENTCNS Milos! , s B ANDLWWe W A'Lm ce IETAME I 1OATM' E ,�.� WCG606S017306.2013A 06@4/2013 0684/2019 ILL EACH ACCIDENT $ 100,000 =mix exaLow? N/A 100,000 ILL DISEASE•EA EtPLOYEE s ORIRTIONOF OPERATIONS Wow LLL DISEASE-POLICY LMEr s 600.000 0CsCnmiON OF OFaATEONn rtCCATION5 MMUS tet.Ad/N&Nl bouts WHOA ray be nediS Ivan Spice Is meta • • • CERTIFICATE HOLDER • CANCELLATION • • SHOULD ANY OF DIE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Nan THE EXPIRATION DATE THEREOF, NOTICE MILL BE DELIVERED IN 36 D y voo Higgins LaneACCORDANCE WITH TIE POLICY PROVISIONS Soulh Yarmouth,MA 02664 NEPRESENTANE • I ACORD 23(2016/03) 015011-2015 ACORD CORPORATION. AB eights reserved. a ' The ACORD name and logo ars registered marks of ACORD MassachUSetflent of Public safety • - Board of Building Regulations and Standards • License: CS-076281 Construction Supervisor • TODD J CANTARA • 7" 10 ECHO RD WEST YARMOUTH MA 02073 '271.4: raeo0 0ker.4— Expiration: • /Commissioner 03/12/2019 CIL CgivesiontaeaS eitograirdraria Office of Consumer Affairs a Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE;IndMdual Realstration gxolratlon 139 11 0. 04/09/2020 TODD CANTARA % D/B/A CAMARA HOME SOULTIONS TODD CANTARA cy..Celat- 10 ECHO RD. " tt- W.YARMOUTH,MA men 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