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Home My WebLink AboutBLD-19-000942 , Og: _ 'OfficeUse Only t' •'4 ! O - ,Permit _ O n 4 .".3 Amount b O y004 .ti„n,. < Permit expires 180 days from issue date ash-P-6 oc9y E C " s-, -F=-131 EXPRESS BUILDING PERMIT APPLI ION i TOWN OF YARMOUTH _AUG 17 2018 Yarmouth Building Department r " J 1146 Route 28 euI 'i_ '" mr:r„ South Yarmouth,MA 02664 )398-2231 Ext. 1261 Q�� 44931 , CONSTRUCTION ADDRESS:3 COIC.J �(v s�� jr1 k �j W W. f ' ASSESSOR'S INFORMATION: . Map: Parcel: • OWNER:UQSILQ \Ley .7)6 \ o st41•Qc 14s W. tco JA/\ 0/6 13 NAME JJ n�� PRESENT ADDRESS TEL # CONTRACTOR: &( Rn2c N Cr 9.5 f auw OD ila9e}i't{ Pat- It/k 02675 // NAME MAILING ADDRESS TEL#So a So q t'i 6KU s sidential 0 Commercial Et.Cost of Construction S&CXDO Home Improvement Contractor Lic.# t!c-g-1 S 7 Construction Supervisor Lic.# 09'316 7 ' Workman's Compensation Insurance: (check one) 0 1 am the homeowner 0 1 e sole proprietor r / " I have Worker's Compensation Insurance 2/ �A Insurance Company Name: d S ,t tC4 v Worker's Comp.Policy# �c6W66 i/a &S�f C I/7 WORK TO BE PERFORMED • Tent _ DuratIon (Fire Retardant Certificate attached?) Wood Stove • Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares 20 ( )Remove existing*(max.2 layers) Insulation Old Kings Highway/Historic 01stq�( )Replacing like for like Pool fencing *The debris will be disposed of at: L 4) ` "'L na ti�— Location of Facility 1 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 aniwer(s) will be just cause for denial or revocation of my license and for pr ecutionecu � under .G.L Ch.268,Section I. Q� / /p' Applicant's Signature: ��. Ca)1Jt Date: Sr / 1 / r O limes Signature(or attachment) '� Date Q //, �//I Approved By: Date: % �� . din rcial(or designee) E ADDRESS: ,i Zoning District: Historical District: 0 Yes ❑ No Flood Plain Zone: 0 Yes G No Water Resource Protection District: Within 100 ft.of Wetlands: • 0 -Yes Cl No 0 Yes 0 No i Q9 _ IC 9041/! iCintileaTi WiekloaCka a S V' el - e ;, Office of Consumer Affairs and Business Regulation 10 Park Plaza- Suite 5170 . Boston, Massachusetts 02116 • Home Improvement..Contractor Registration • ((r ,._ _=- Type: Individual t^" F-__? 71 -= - Registration: 128957 OLNER KELLY = t _ ' �,.,, r Expiration 06/13/2019 8 RHINE RD E-_ - .,i, • YARMOUTHPORT MA 02675 ' T - 11 ' 1'f .::�r.If r q\� _. Jv7-: ` Update Address and return card. Mark reason for change. SCAt 0 20M.05/11 —— -- _ Oi1sidress n?,ne_!ivt rl c,nolooment 0 Inst Card c c' mmommcal/Ac/of1auncAruela Office of Consumer Affairs&Business Regulation Q; "-"'� HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only �� TYPE:Individual before the expiration date. If found return to: Reoistratlon Exnitmaga Office of Consumer Affairs and Business Regulation :, -- 128957 06/13/2019 10 Park Plaza-Suits 5170 OVER KELLY I V'.1 -3 - -,:ng&1A 02116 • OUVER M KELLY ‘ -i 7\Y.:el.,'\TL---li,it,') 00:07/ -7;1 7--;-,;,,:."7 7:::;“ g . . t� , e 8 RHINE Not valid without signature ) . YARMOUTHPORT,MAI 02675 Undersecretary . • Commonwealth of Massachusetts • • ix Division of Professional Licensure Board of Building Regulations and Standards Constructio SUp4ttvj,cprSpecialty CSSL-099167 i. Emires:09/28/2019 L . i i a t1 OLNER M KELLY -41 ' - 8 RHINE ROAD, ✓f YARMOUTH PORT MA 02676 +: r.,,,°., Commissioner 12 • The Commonwealth of Massachusetts _-. i Department ofIndustrialAccidents r =:cit►i= 1 Congress Street,Suite 100 c, Boston,MA 02114-2017 ir ':r��„r� www.mass gov/dia Workers'Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information / UD (Q � Please Print Legibly Name(Business/Orgi 'on/Indiv(dual): KEac-USG IV0._ Address: ? wi, ' City/State/Zip:442-K t`1,1Odi lePhone#: 50(6 SCP (-{ bL(V Are you an employer?Cheek the appropriate box: Type of project(required): I.1am a employer with employees(full and/or part-time).* T. 0 New construction 201 am a sole proprietor or partnership and have no employees working forme in 8. 0 Remodeling any capacity.[No workers'comp.insurance requited.] 3.0 I am a homeowner doing all work myself No workers'comp,insurance required.]t 9. ❑Demolition 10 0 Building addition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. 1 will ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.01 am a general contractor and I have hired the sub-contractors listed on the attached sheet These have employees and ham workers'comp.insurance” 13 Roof repairs 6.0 We am a corporation and its offices have exercised their right of exemption pa MGL e. 14.0 Other 152,"41(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box ft must also fill out the section below showing their workers'compensation policy information. t Homeowner who submit this affidavit indicating they am doing all work and then hire outside contractors must submit a new affidavit indicating such • factors that check this box must attached an.4de1 tshowing the cent at the sub-contractorsandstatewhetherornotthoseentitieshave 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. 1 ^ . ' AAZ Insurance Company Name: /— C 4PA Policy#or Self-ins. ILic.#: (O S(02()6cc te1.0 4) 4C5( tic Expiration Date: l 't- 1 10 !Y-O\9 Job Site Address:3t0 CD•\CS*&AC v t\ City/State/Zip:(j . Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration!date). Kik 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$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereb ., , the p ' and p o erjury that the information provided above is true and correct Signature. G air^ ''^^(�� Date: ti i 2 L$ Phone#: �D 50� (,cU TO • 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#: A G% CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDNYYY) 05/18/2018 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(les)must 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 NAME: Joanna Bednark DOODLING&O'NEIL INSURANCE AGENCY Vicar o.Eau: (508)775-1620 FAX Nal: EJIAIL ADORESs. jbednark@doins.com 973 IYANNOUGH RD INSURER(S)AFFORDING COVERAGE NAILS HYANNIS MA 02601 INSURER A: ACE AMERICAN INSURANCE CO 22667 INSURED INSURER B: KELLY ROOFING INC INSURER C: INSURER D: 8 RHINE RD INSURER E: YARMOUTH PORT MA 02675 INSURER F: COVERAGES CERTIFICATE NUMBER: 270693 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, OCCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ID ADOLSUBR POLICY EFF POLICY EXP LIMITS LTR INSO wan POLICY NUMBER (MMDIYYYYI MMIDDIYYYYI COMMERCIAL GENERALLIABILITY EACH OCCURRENCE i NIIEU CLAIMS-MADE Q OCCUR PREMI ESO(Ea occurrence) $ MED EXP(Any one Anon) $ N/A PERSONAL B ADV INJURY $ GENL AGGREGATE UMIT APPLESI� PER GENERAL AGGREGATE $ HPOLICY JEPRE4 1 1 LOC PRODUCTS-CC.P/OPAGG $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea aoddenq ANY AUTOBODILY INJURY(Pets/non) $ ALL OWNED _AUTOS AUTOS N/A BODILY INJURY(Pet accident) $ HIRED AUTOS _ JUTOS (POMEDRer welded) MAGE $ UMBRW.A LIAR HocEACH OCCURRENCE EXCESS LAB CLAIMS-NUDE N/A AGGREGATE f DED I RETENTION$ $ WORKERS COMPENSATION �/ I IND EMPLOYERS UABILTY /�I STATUTE ER ANYPROPRETORIPARTNEREXECUTIVE ww WA WA 6S62U88H08580918 05/10/2018 05/10/2019 E.LEACHACCIDENT $ 500,000 A (Mandatory ( atom In HH) EL.E.L DISEASE-EA EMPLOYEE $ 500,000 I es.SCemabe UMm DESCRIPTION OF OPERATCNS below E L DISEASE-POLICY LINT $ 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD tot.Additional Remarks Schedule,may ea attached Imam apace Is r.qulnd) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay daims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of instance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.govAwdlworkerscarnpensationfinvestigationsf. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELNERED IN Town of Mashpee ACCORDANCE WITH THE POLICY PROVISIONS. 16 Great Neck Road North AUTNORIZEDREPRESENTATIVE Mashpee MA 02649 p�C.� CroN y,CPCU,VicePresident—ResidualMarket—WCRIBMA 01988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD