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Home My WebLink Aboutbld-20-003756 • Use Only o O - \1.1- .. g 7 E Amount 4. ,"`'+;' 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: 32 DRIFTWOOD LN SOUTH YARMOUTH, MA 02664 ASSESSOR'S INFORMATION: Map: A 7 Parcel: 57 OWNER: KELLY GRACE 32 DRIFTWOOD LN SOUTH YARMOUTH, MA 02664 774-212-0443 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$ 13,500 Home Improvement Contractor Lic.# 182457 Construction Supervisor Lic.# 106040 Workman's Compensation Insurance: (check one) ❑ 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 Replacement windows:# Replacement doors: # Roofing: #of Squares 20 (X)Remove existing*(max.2 layers) Insulation 6.e0ge-o A ,► ► f Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing (`yVT'I['�'a� *The debris will be disposed of at: Yarmouth transfer station Location of Facility I declare under penalties of perjury th en 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 ion of Ii e and for prosecution under M.G.L.Ch.268,Section 1. , Applicant's Signature: Date: F on �02 0 Owners Signature(or a chment) �•Qrr Date: Approved By: Date: r' ' 7 - p`O Building Official(or designee) EMAIL ADDRESS: Zoning District: Historical District: 0 Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: ❑ Yes ❑ No ❑ Yes 0 No 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 am 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: $ /3 5'O If acceptable, initial here: Payment will be made as such: Pt Deposit 1/3 $ % S'OZS Start day payment 1/3: $ '{ it Upon completion 1/3: $ Date: / �13j� Signatures: •� � � Note:No work shall begin prior to the signing of the contract and transmittal to the owner of g 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 Office of Consumer Affairs and Business Regulation One Ashburton Place- Suite 1301 Boston, MaAchusetts 02108 Home Improvem tractor Registration r~ Type: LLC t . Registration: 182457 BELCAPE CONSTRUCTION LLC x`t ' Expiratlarl. 02/05/2020 42 WOODBURY AVE r - " `} HYANNIA,MA 02601 ;- Te& 6' "'C" 6- ,rs 4 r Update Address and Return Card. SCA 1 0 20M-05/17 K2vru»uvuPwad/fn{.11., a�fKwdii Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only 7 YPE:LLC before the expkation date. If found return to: Regime E Office of Consumer Affairs and Business Regulation yaNNW,,Wi 02/05/2020 10 Park Plaza-Suite 5170 BELCAPE CQt.S1 tt ;a gt,4 Boston,MA 02118 17 ARLOU DZIANIS ""*' 'e� 42 W OODBURY AVE- HYANNIA,MA 02601 Undersecretary / of valid without signature • • a ....;*..r...,..V ..,.,. G7 r.... .,..:�-ssv ...... ........�t,. .,..�tv Commonwealth of Massachusetts Division of Professional Licensure kl./ Board of Building Regulations and Standards Constructi ,t` 1Mdr Specialty CSSL-106040 3 k s : yires: 05/14/2020 r :e, 1 z , s ,4 ANATOLI SIVSIt r . 27 MILL PON D t fi„ WEST YARMO '1, ►`~ ,t,,,. 1 Coe/06p 40.00••• Commissioner itd CERTIFICATE OF LIABILITY INSURANCE DATE THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND COS NO RIGHTS UPON TIE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY ANEW, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSUNtER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the poncypes)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terse and conditions of the policy,certain ponies may require an endorsement A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsecnent(s). PRODUCER NotTACT Victoria Sharapova insuranceALD e Mc' Ear 617 787-7877 rFAI Net 617-78T-7876 02134Allston,MA venue - INSOMESIOAFFORDINGCDVBiME NAaa Ianss s$, ATLANTIC CASUALTY INS CO 42846 INSURED Belcape Construction Inc INSURERS: AMGUARD INSURANCE COMPANY 42390 42 Woodbury Ave Wws®ec: Hyannis,MA 02601 WIIi D: I SURERF: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE USTED 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 DOCUTAENT WITH RESPECT TO V*IICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE`INSIJRANCE 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 CLAWS. POLICY EFF POUCY OP TYPEOFWIURPMCE asD yap POLICYmmaBt INDLOOIYYTY1 AINIODMYYTI UNITS T A JT COMMERCIAL GEIBRAL a an w y L261002952 02106/2019 D2/06/2020 EACHOCCURRIDICE s 1,000,000 CIAIUSMACE VI OCCUR SS traiO nci $ 100,00E MED DIP(Any mammon) $ 5.000 PERSONALS ADV INJURY $ 1,000,00E GEN'L AGGREGATE LW E APPLIES PER: GENERAL AGGREGATE $ 2,000,00E POLICY JECT rn I WC PRODUCTS COMPAP AGG $ 2,�,� OTHER: $ AUTONOB11.ELussurY COMBINEDLIT $ ANY AUTO BODILY WJURY(Pr parson) S SCHOXS.AUTOS ®ONLY HIRED `AU7 BODILY INJURY(Prraoddrq $ PROPERTY DAMAGE _AUTOS ONLY _AUTOS AUIYINED (Par i S UMORELLALWB OCCUR EACH OCCURRENCE S EXCESS LIAO CLAMS MADE AGGREGATE $ Der [amnion s s B WORKERS l oY it ATION R2WC085768 02/12J2019 02/12/2020 VI siTairrE gr. MO ANY PROPRIETORIPARTNERIEXECUTIVE YIN ELI N!A I EACH ACCIBOIT $ 1,000,000 OFFICER/NEWER OCCLUDED?Mandatary In El.DISEASE-EA EMPLOYEE $ 1,000,000 legaltP71014.621beOOPERATIONSbdor El.D -POUCYLIMIT '$ 1,000,00E COICRIFITONOFOPERATIONS:LocAT10Nnivl*cLms(ACORD NM.Additional ibwA.sSolrains.may beaMiWntlsmon apace Mngiied) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TIE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIIERED IN ACCORQANCE WITH THE PCUCY PROVISIONS. AUDIOTaZED REPRESENTATIVE rO 1986-2015 ACORD CORPORATION. AN rights reserved. ACORD 25(2016/03) The ACORD name and logo ate registered remarks of ACORD The Commonwealth of Massachusetts _ Department of Industrial Accidents I 'E- ?lid+..=./ Office of Investigations r " _=�= Ar 600 Washington Street __'�''- t 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 6. New construction employees(full and/or part-time).* have hired the sub-contractors 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. Plumbing 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 ✓ Roofin employees. [No workers' D. Other g 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. 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: 32 DRIFTWOOD LN SOUTH 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 for insurance coverage verification. I do hereby certify "f' pains n, ,enalties of perjury that the information provided above is true and correct. /q / Date: Signature: , 1/6/2020 Phone#: 58•-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#: