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HomeMy WebLinkAboutBld-20-001849 ,Y Office Use Only o 4R,� ' o ri# 00 /F if • di• or O �r y Amount • `" t c t Permit expires 180 days from issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 LT - <- 1-01 Ci South Yarmouth, MA 02664 000 333 45 (508)398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 15 YANKEE DR SOUTH YARMOUTH ASSESSOR'S INFORMATION: Map: Parcel: OWNER: SMITH CHRISTOPHER 15 YANKEE DR SOUTH YARMOUTH, MA 02673 508 694-7335 NAME PRESENT ADDRESS TEL. # CONTRACTOR: BelCape Construction 42 Woodbury Ave Hyannis, MA 02601 508-685-9720 NAME MAILING ADDRESS TEL.# Residential 0 Commercial Est.Cost of Construction$ 9,000 Home Improvement Contractor Lic.# 182457 Construction Supervisor Lic.# 106040 Workman's Compensation Insurance: (check one) D I am the homeowner 0 I am the sole proprietor XI have Worker's Compensation Insurance Insurance Company Name: AmGuard Worker's Comp.Policy# R2WC085768 WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares 7 sq 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: S&,1 EXCO Dennis Location of Facility I declare under penalties of perjury that the,statements herei 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 revvoccati of my license prosecution under M.G.L.Ch.268,Section I. Applicant's Signature: C-± -. --- Date: 10/3/2019 Owners Signature(or stta me ✓ Qle Date: 10/3/2019 Approved By: et" Date: 4f- V—77 Building Official(o ign EMAIL ADD . belcapeconstruction@gmail.com Zoning District: Historical District: E Yes L No Flood Plain Zone: C Yes C, No Water Resource Protection District: Within 100 ft.of Wetlands: Yes Li No 0 Yes E No The Commonwealth of Massachusetts _" r/ Department of Industrial Accidents = ini` 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 Informatiqp Please Print Legibly Name (Business/Organization/Individual): BeiCape Construction Address: 42 Woodbury Ave Hyannis, MA 02601 City/State/Zip: Phone#: 508-685-9720 Are you an employer?Check the appropriate box: Type of project(required): 1)Lig I am a employer with 3 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 8. Remodeling any capacity.[No workers'comp.insurance required.] 3. I am a homeowner doingall workt 9. ❑Demolition ❑ myselt[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.❑Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.0 Roof repairs These sub-contractors have employees and have workers'comp.insurance.* 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.gOther Siding 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *My 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 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: AmGuard Policy#or Self-ins.Lic.#: R2WC085768 Expiration Date: 02/12/2020 Job Site Address: 15 YANKEE DR City/State/Zip: S.Yarmouth, MA 02673 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 certify un e pains penalties of perjury that the information provided above is true and correct Signature: Date: 10/03/2019 Phone#: 508 8f85-9720 Official use only. Do not write in this area,to be completed by city or town official City or Town: PermitlLicense# 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#: 4 attic should be removed. BELCAPE CONSTRUCTION, LLC is not responsible for any damages if said items remain in place. Curtains, drapes and window and door treatments may need proper reinstallation or replacement by customer due to sizing on any window or door replacements and is not included in jobs contracted with BELCAPE CONSTRUCTION,LLC Any alteration or deviation from above specifications involving extra costs will be executed only upon written orders and will become an extra charge over and above the estimate.All agreements contingent upon strikes,accidents or delays beyond our control.Owner to carry fire,tornado and other necessary insurance upon above work. Workmen's Compensation and Public Liability Insurance on above work to be taken out by BELCAPE CONSTRUCTION, LLC. No lien or security interest will be placed on the residence as a consequence of the contract. Owners who secure their own construction-related permits or deal with unregistered contractors will be excluded from acces o the guaranty fund. This Contract not valid unless signed by Company Representative Acceptance of Estimate The above prices, specifications and conditions are satisfactory and are hereby accepted. BELCAPE CONSTRUCTION, LLC is authorized to do the work as specified. Contract total: $ '? 000 If acceptable, initial here: Payment will be made as such: P'Deposit 1/3 $ Start day payment 1/3: $ Upon completion 1/3: $ Date: Signatures: Note:No work shall begin prior to the signing of the contract and transmittal to the owner of a copy of such contract. You, the buyer may cancel this transaction at any time prior to midnight of the third business day after the day of this transaction. Accepted :p Date:P1/j3 THIS PAGE IS PART OF AND IN CONFO' CE W PROPOSAL: 15 Yankee r South Yarmouth trz t -ii9r,Aci,-44a64/48tee4 Office of Consumer Affairs and Business Regulation One Ashburton Place - Suite 1301 Boston, Mastitchusetts 02108 Home lmprovemear.ehtr actor Registration Type: LLC BELCAPE CONSTRUCTION LLC Registration: 182457 Expiration: 02/05/2020 42 WOODBURY A'VE HYANNIA,MA 02601 • v "4‘ Update Address and Return Card. SCA 1 0 20W6/17 Kiteneivenct,effiXt>/:itcrAfezt>434(4 Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:LLC before the expiration date. If found return to: • Eggigdfigg Office of Consumer Affairs and Business Regulation 02/05/2020 10 Park Plaza-Suite 5170 BELCAPE coNs1fiutilt0,# Boston,MA 02116 ARLOU DZ1ANIS 42 WOODBURY AVE-. HYANNIA,MA 02601 ot valid without signature Undersecretary • • Commonwealth of Massachusetts Irt Division of Professional Licensure Board of Building Regulations and Standards ConstructiolhVispr Specialty CSS L-106040 pires: 05/14/2020 ANAToli SIVtTSKI I r I. 27 MILL POND Ay :,441tibk, WEST YARMOl1.T MA u 3 ` Commissioner • ACCPREPIr CERTIFICATE OF LIABILITY INSURANCE DAM M TY) THIS CERTIFICATE IS ISSUED AS A 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 POUC ES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN TIE ISSUING I SURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND TIE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the polcy(les)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WANED,subject to the tens and conditions of the policy,certain policies may isquke an endorsement. A statement on this-certificate does not confer rights to the certificate holder In lieu of such endorsement(s). Pam CCMTACT Victoria Slueapova AW Insurance Agency Inc. NAIM wow BOA Brighton Avenue Eat 617-787-7877 r FAx Vol 617-787-7876 Alston,MA 02134 MONISM E IS)AFFORDNGCDVERAGE AMC gest$IERA, ATLANTIC CASUALTY INS CO 42846 emurmo BB Construction Inc sosuRERB: AMGUARD INSURANCE COMPANY 4239042 Woodbury Ave Hyann s,MA 02601 INSURER C: INSURER D: INSURER E INSURER F: COVERAGES CERTIFICATE NUiMEfD REVISION WAVER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE USTED BELOW HAVE MO ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.D. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUB.ECT TO ALL RE TERMS. EXCLUSIONS AM)CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLANS. HER POLICY MP LTR TYPE OF N Ma SURANCE ^eso wvD POUCY MER mi YYYW} IMM On Y1 U_TI A coametcm.cat.w►esuTy y L261002952 02106/2019 02/06/2020 I EACH OCCURIumcs s 1,000,000 CLAMS-MADERENIED f A OCCUR PR g Ea 1 s 100,000 MEDEXR(Arsseperson) $ 5,000 PERSONAL&IU)VINJURY $ 1,000,000 GENT-AGGREGATELaIT APRJ PER: GENERAL AGGREGATE $ 2,000,000 POLICY I I Mi t LOC I PRODUCTS-CO P AGO $ 2,000 000 Met a AUTOMOBILE UNAUnY WARMED SINGLE LAeT $ ANY AUTO BOOLY*WRY(Pr prison)— OWNED —SCHEDULED $ _ Y ,_. 00DLAUTOS Y INJURY(Par sodding) $ _ AUTOS ONLY AUTOS ONLY ZiPTY; $ $ UMERBaA LUIS OCCUREACH OCCURRENCE $ _ EXCESS UM CUMIS#AADE AGGREGATE $ DED I I RETENTION s $ g oYERS AND EMPL *WARM R2WC085768 02//212019 02/12/2020 VI STATUtS g Y ANY AT Y� A EL EACH ACQC$ T $ 1,000,000 EXCLUDED? N Mandatory dmeaaekl Ee.L DISEASE-EAEMPLOYEE $ 1,000,000 DIMAPnDN OF OPERATIONS below I EL O(BE.SE-POUCY tow s 1,000,000 DESCRIPTION OF INVITATIONS/LOCATIONS fVEHICLES(ACORO TN,AdddaalReeaks3ohmdue,say isaeee udEearmonokieq sd) CERTIFICATE HOLDER CANCELLATION SHOW)ANY OF THE ABOVE DESCRIBED POLICES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELVER® IN ACCORDANCE WITH TIE POUCY PROVISIONS. AlE1NON/GM REPRESENTATIVE ©1988 2015 ACORD CORPORATION. AS rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD