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HomeMy WebLinkAboutBLD-23-003813 Office Use Only Og.Y444,4 . Permit# 0 -IN ` �H; "Amount '� wwn In s E d r Permit expires 180 days from • issue date EXPRESS BUILDING PERMIT APPLICATI i P E C E I V E D TOWN OF YARMOUTH Yarmouth Building Department JAN 1A 2023 1146 Route 28 South Yarmouth, MA 02664 B uI 1.I1 I t 45- ENT (508) 398-2231 Ext. 1261 --- CONSTRUCTION ADDRESS: 1007 West Yarmouth rd Yarmouth Port rJU 23��73t�I3 ASSESSOR'S INFORMATION: Map: Parcel: owNER: FLETT BRUCE 4 Frothingham rd Burlingtca 617-908-3003 NAME PRESENT ADDRESS TEL. # CONTRACTOR: BelCape Constr 133 Old red top rd Brewster 508-685-9720 NAME MAILING ADDRESS TEL.# El Residential 0 Commercial Est.Cost of Construction$49,000 Home Improvement Contractor Lic.# 198000 Construction Supervisor Lic.# 106040 Workman's Compensation Insurance: (check one) ❑ I am the homeowner 0 I am the sole proprietor El I have Worker's Compensation Insurance Insurance Company Name: AmGuard Worker's Comp.Policy# R2WC335516 WORK TO BE PERFORMED Tent L Duration (Fire Retardant Certificate attached?) Wood Stove U 1 Siding: #of Squares Replacement windows:#32 Replacement doors: # Roofin : #of Squares (❑)Remove existing*(max.2 layers) Insulation n Old Kings Highway/Historic Dist Re lcin like for like Pool fencing�Replacing n I/03 3 — d►L 1'IU fr \ t ` e —144-^ n "The debris will be disposed of at: S&J Exco Dennis 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 revo on of m nse and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Si - Date: 1/12/2023 Owners Signs e(or ttaclrment) / Date: Approved By: ``' ✓ Date: / AR Building cial desi ee) EMAI DRESS: beleapeine(aagmail.com Zoning District: Historical District: ❑ Yes 9 No Flood Plain Zone: ❑ Yes [I No Water Resource Protection District: Within 100 ft.of Wetlands: D Yes ❑ No ❑ Yes 9 No 3 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, INC. 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 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, INC is authorized to do the work as specified. Contract total: $ t,42- If acceptable, initial here: Payment will be made as such: Pt Deposit 1/4 $ �23 Start day payment 1/2: $ j Dab Upon completion 1/4: $ Date: 10f Wi ZZ— Sig natures`4� 4'4"'"? �� —C 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: p ‘14.26.------ Date: r HIS PAGE IS PART OF AND IN CONFORMANCE WITH PROPOSAL: 1007 W Ya 'Tmouth Rd Yarmouth Port THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Aff-,li'sr, • Business Regulation 1000 Washing p = -Suite 710 Bosto Home im•ro;"� `'` '=�` •istration :Zig Corporation (type: • bon: 198000 BELCAPE CONSTRUCTION INC :i !bon: 02/18/2024 133 OLD RED TOP RD BREWSTER,MA 02631 '� 11- fl_ _.. 44, SVe Update Address and Return Card. cs (-) to 4:11 r.., U) r- ii X)ti, al MI 01 21 0 1 01.'.. -.., gg. C9 t 1 3 5 4 0 0 vi ow ; El it 1 0 Z t 1.4 ii• A 1$ CERTIFICATE OF LIABILITY INSURANCE DATE 05/03/2022) 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 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 certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms 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). PRODUCER CONTACT Victoria Sharapova ALD Insurance Agency Inc. PHONE 617-787-7877 FAX 617-787-7876 60A Brighton Avenue INC.No.Ext): (NC No): Allston,MA 02134 E-MAIL comm aldinsurance.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC A INSURERA: ATLANTIC CASUALTY INS CO 42846 INSURED Belcape Construction Inc INSURERB: AMGUARD INSURANCE COMPANY 42390 133 Old Red Top Rd Brewster,MA 02631 INSURER C INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES 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 CLAIMS. INSR ADDL SUBR POLICY EFF POLICY EXP L7R TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY1 LIMITS A V COMMERCIAL GENERAL UABIUTY L261002952 02/06/2022 2/06/2023 EACH OCCURRENCE $ 1,000,000 l CLAIMS-MADE ' v l OCCUR DAMAGE TO RENTED 100,000 PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY JECT LOC PRODUCTS-COMP/OP AGG $ _ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY _ AUTOS ONLY (Per accident) ._ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATION R2WC335516 02/12/2022 02/12/2023 VPER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ I I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Cape Home Designs Inc ACCORDANCE WITH THE POLICY PROVISIONS. 4 Great Western Road Harwich,MA 02645 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents t- == +=Eel Office of Investigations 600 Washington Street �'— Boston, MA 02111 •�.►-1` www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): BelCape Construction Address: 133 Old red top rd City/State/Zip: Brewster, MA 02631 Phone #: 508-685-9720 Are you an employer?Check the appropriate box: Type of project(required): 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' [No workers' comp. insurance comp. insurance. 9. Building addition 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 employees. [No workers' 13. ✓ Other Windows 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.#: R2WC335516 Expiration Date: 02/12/2023 Job Site Address: 1007 West Yarmouth Rd City/State/Zip: Yarmouth Port, MA 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 un r the pain and penalties of perjury that the information provided above is true and correct Si ature: P Date: 1/12/2023 Phone#: 5 -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#: