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Home My WebLink AboutBld-20-003755 � 7 Office Use Only ,t -e2i#1 o' ,1 S t : Amount •F�,w c•�� . � /� Permit expires 180 days from • .?~' �(> issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: / _ 39 4/M/.ra s, ✓r iZ ASSESSOR'S INFORMATION: Map: , S Parcel: 91 OWNER: David Devivo 101 WIMBLEDON DR ST SIMONS ISLAND, GA 31522 912-434-6451 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$ 15,000 Home Improvement Contractor Lic.# 182457 Construction Supervisor Lic.# 106040 Workman's Compensation Insurance: (check one) ❑ I am the homeowner ❑ 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 Replacement windows:# Replacement doors: # Roofing: #of Squares 15 (X)Remove existing*(max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: Yarmouth transfer station Location of Facility I declare under penalties of perjury the 'e stateme in 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 re 'on of my li d for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: -�-�"`�' _ Date: Owners Signature(or ttachmeat) 4 Date: Approved By: / 7— olodo - — Date: Building Official(or designee) EMAIL ADDRESS: Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: CI Yes ❑ No ❑ Yes ❑ No 6 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 exclud om access to the guaranty fund. This Contract not valid unless signed by Company Representativ 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: $ f 6'e,c0 If acceptable, initial here: Payment will be made as such: 1'Deposit 1/3 $ a1 f .5`G2) Start day payment 1/3: $ 'r Upon completion 1/3: $ Date: 42 713/f I Signatures: a - 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 By: Date: THIS PAGE IS PART OF AND IN CONFORMANCE WITH PROPOSAL:32 Driftwood Ln South Yarmouth r kgt• Commonwealth of Massachusetts pi Division of Professional Licensure Board of Building Regulations and Standards Constructio S 1 r Specialty CSSL-106040 '.x,. � Spires: 05/14/2020 „, — ANATOLI S SI - v; ,t , 1140* 27 MILL PON r.00 �,D ' WEST YARMO M `s 4 `�` Commissioner itati-0•*- ei rti icui a aI icoo ricyuiauun One Ashburton Place - Suite 1301 Boston, Massachusetts 02108 Home Improvem tractor Registration • Type: LLC BELCAPE CONSTRUCTION LLC t '- Registration: 182457 42 W OODBURY AVE ,; �_ Expiration: 02/05/2020 HYANNIA,MA 02801 Update Address and Return Card. sCA 1 0 20M-05/17 Ki:vitme arpe.a44i n Ajaara urn/Gs Office of Consumer Affairs&Business Regulation HOME IMPROVFNIENT CONTRACTOR Registration valid for Individual use only Tom:LLC before the expiration date. if found return to;• glandign Office of Consumer Affairs and Business Regulation 02/05/2020 10 Park Plaza-Suite 5170 BELCAPE CO Boston,MA 02116 ARLOU DZIANIS �- ZollOgelli..�/ 42 WOODBURY AVE HYANNIA,MA 02801 Undersecretary / of valid without signature .ttEc3,Rd CERTIFICATE OF LIABILITY INSURANCE DATE ov1 019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AN CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEN. EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POUCIES 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,thepolcypes)must have ADDITIONAL INSURE)provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the tens and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). oaNnacr PRODUCERBAOA Ir xancee Inc. �Victoriag 7-7877 FAX 617-787-7876 righton Avenue tuft, ay.am Allston,MA 02134 ADDIEse: MSJRERES)AFFORDING COVERAGE MAD e C A: ATLANTIC CASUALTY INS CO 42846 MIMED Belcape Construction Inc mums: AMGUARD INSURANCE COMPANY 42390 42 Woodbury Ave Hyannis,MA 02601 mums c: INSURER D: MUM F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POUCIES OF 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 CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLANS. INSR WEIR OF PODGY EIP LTR TYPE OF INSURANCE u 1 WD POLICY NUMBER mmMCQ YTYI felIWOOMYYTI LOOTS A J COMMERCIAL eman .UAalury y 1261002952 02/06/2019 02106t2020 Each opcunne cn $ 1,000,000 C ATMs-MADE OCCUR MSS t Ea R � : 100.000 MED DP(Any one person) s 5,000 PERSONAL&ADV INJURY $ 1,000.000 GENT.AGGREGATE MOT APPLIES PER: GENERAL AGGREGATE s 2,000,000 PDuCY f—1 PRODUCTS-(�1�/OPAN3G_ $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY cameo SINGLE T $ (Ea widare ANY AUTO BODILY INJURY(PrPrsore $ _ HIREDAUTOS ONLY _ AUTOS PROPER1YDAMAGE $ AUTOS ONLY _ AUTOS ONLY (Per mote* $ taORELLA Wa OCCUR EACH OCCURRENCE $ EXCESS UNE pJUMSMADE AGGREGATE $ DED I RETENTION$ $ B WORfiHRCOMPENSATION R2WC085768 02/12/2019 02/12/2020 VI sPlakivrE AND ErPLOYERB LIABLITY { ANY PROPi TORIPAATNMIERECUTME Y� N t A 1 EL EACH ACCIDENT $ 1,000,000 OFFIAa CERMBISER EXCLUDED? 'EL DISEASE-EA EMPLOYEE $ 1,000,000 DESCRIPTION OF OPERATIONS below EL DISEASE-P(M.ICY Leer s 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VIMICLES(ACORDROT,Additional Remarks Wheelie.may 0eaeadreda mole spine Yrequired) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POUCHES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE OELNE D IN ACCORDANCE WM TIE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE m 19888-2015 ACORD CORPORATION. AN rights reserved. ACORD 25(2016 3) The ACORD Warne and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents ` '—-1j=r/ Office of Investigations • 600 Washington Street • =-1:1— Boston,MA 02111 ;•:.��'` www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): BelCape Construction Address: 42 Woodbury ave City/State/Zip: Hyannis, MA 02601 Phone#: 508-685-9720 Are you an employer?Check the appropriate box: Type of project(required): 1. 1 I am a employer with 3 4. I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. New construction 2. I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling ship and have no employees These sub-contractors have 8. Demolition working for me in any capacity. employees and have workers' 9. Building addition [No workers' comp.insurance comp.insurance.: required.] 5. We are a corporation and its 10. Electrical repairs or additions 3. I am a homeowner doing all work officers have exercised their 11. Numbing repairs or additions myself. [No workers'comp. right of exemption per MGL 12. Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.✓ Other Roofing 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. tContractors 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: 39 ALMIRA RD City/State/Zip: S Yarmouth, MA 02644 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA f urance coverage verification. I do hereby certify un e pains and penalties of pedury that the information provided above is true and correct Signature: -- Date: 1/6/2020 Phone#: 08-685-9720 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#: