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Home My WebLink AboutBLD-19-001109 RECEIVED otr`"«�Use Only ��(}} y 3 .iR'rc a AUG 23 2018• o •±+,,z - i 'Amount Te e % .,......, cr,d. �• '�rvG. . ',Permit expires 180 days from , :issue daze • EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 • x(5508)398-2231 ��Rxt. 1^2611 CONSTRUCTION ADDRESS:3S C`-OV\ C Veer!) O . '-i(pt-48\403`t,, ASSESSOR'S INFORMATION: / Map: n Parcel: OWNTR: ` 1ACIMAs ��.►ON) �s (uo.)en- Q D 1A). .a.n,t rrA MA. C061.3 NAME PRESENT ADDRESS1TEL # CONTRACTOR: k'�tiii R.Q.ct r)C `33C. 95. fu.AA)6. P. 4.46,,,,Ipv, 0267$ NAME MAILING ADDRESS #SocfSoq cib((.O Lang 13 Commercial r Est Cost of Construction$ &n es Hou Improvement Contractor tic.# 1�v 1�� 1 Construction Supervisor Lie.# (y i t 1 67 Nikti nan's Compensation Insurance: (check one) D Ism the home° ae ��❑ I the sole proprietoro� �� ❑ I have Worker's Compensation Insuranceu / t/ Ince Company Name W t\f r.,\ Worker's Comp.Policy#f 0&tj 6��f�%SS�1 0 WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #offSquares Replacement windows:# Replacement doors: # Roofmg. #of Squares I% ( Remove existing*(max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing Y`�ln^ nn � J �Q , 'The debris will be disposed of at 4.�s ) k. 1. `` -- Location of Facility I declare under penalties of.-'ury that the statements herein .. • ed are hue and correct to the best of my knowledge and belief I understand that any false answer(s) will be just cause for• ion of licensees .ecution under MG.L Ch.268,Section 1. ( �r� 18 Applicant's Signamre.c ill��, p' • • Date: V ( LL j LD 4 Owners Signature(or attachment) `` ,A, 9 Date: �+*�• ��g'111 t% Approved BY )tg �/ J 5; �.J—/8 Date: gam:. uv(or(tesignee) DRESS: 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 0 No ❑ Yes 0 No The Commonwealth of Massailtusetts Department oflndustrialAccidents =:"alb _Fir= @ 1 Congress Street,Suite 100 J n I_T_>" Boston,MA 02114-2017 www.mass gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH TILE PERMITTING AUTHORITY. Applicant Information / � Please Print Legibly Name(Business/OKca 'oa/lndividual): aQoyi s-U� kW._ Address: 9 t LLCJA City/State/Zip:4PaRei1 iPC4 Oao fgPhone#: So Soo( q bLt Are you an employer?Check the appropriate box: Type of project(required): 1.j6am a employer with employees(full and/or part-time).* 7. 0 New construction 10 t am a sole proprietor or partnership and have no employees wodring forme in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 9. CI Demolition 3.0 I am a homeowner doing all work myself[No workers'comp.humane required.]t 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. t wll 10 ❑Building addition 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 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13„�ROOf repairs These hove employees and have worime comp.insurance.? 6.0We are a14.0Other corporation and its officers have exercised their right of exemption perMGL c. 152,51(4),and we have no employees.[No wakes'comp.insta required] *Any applicant that checks box 61 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 contactors 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 orb-conwstors 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 fob site information. �nA ` Insurance Company Name: C./- (� n r� Policy#or Self-ins.Lic.#: bdsG2(')Q,%IAD E %C7°( (g Expiration Dale:: M1 J 9-o9 SS C-1-04Job Site Address: C-1-04 Q. b City/State/Zip:W• f it 1 Mct 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 DLk for insurance coverage verification. I do hereb ,,. the p ' and p o ern that the information provided above true and coed. p, Signature. G ' ,r Date: lc 23 ( � t Z� Phone#: �g 5O' �,(a+-O 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#: • _4 U f2Pi Wowee/J92QOZ��Berm 'G 4/��>r gzoo(.1 keetee . _ S t. yOffice of Consumer Affairs and Business Regulation 10 Park Plaza- Suite 5170 • Boston, Massachusetts 02116 . Home Improvement:Contractor Registration r i c,.,` ---_-_7 rr-1 Type: Individual _,_-c, br i Registration: 128957 OLIVER KELLY ---- t rte-- .. ` Expiration: 06/13/2019 8RHINE RD ! a is•= .. ===' ,, . YARMOUTHPORT,MA 02675 :I = = t \Y; •'__ i-'t r . jc " /y • ' yr _ Update Address and return card. Mark reason for ch sCAt 0 20M.o5r11 ---- -•------ _ �--._. ..-._._,Y_0 Addr, f-i! w,L l ri PoMoynn.nt 0 Ley c/2€ ¢c o,rlmosturall&c/2l�nuarAtcxcit . Office of Consumer Affairs&Business Regulation .,,� HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only -_ ,--:: :27:128.957- TYPE:Individual . before the expiration date. If found return to: pealstrotio0 Emlrotian • Office of Consumer Maks and Business Regulation 08/13!2019 10 Park Plaza•Sufis 5170 R KELLY..t:.#:".4,-; = §oaton"'Ng 02116 .��—• �. .. A� 8 RHINE M.KELLY'. _ \� r•GQ �,„. ��• i tIRHBVERD. ' � �� U � - YARMOUTHPORT.MA 02675 Undersecretary Not valid without signature • • • Commonwealth of Massachusetts ' U Division of Professional Licensure Board of Building Regulations and Standards • CanstructionSliperAsgr Specialty CSSL-099167 Ej�ires:09/28/2019 - a OLIVER M KELLY ._+ ! = ••• ' • • • 8 RHINE ROAD, 1,,: ' • YARMOUTH PORT MA 02876 ` y.,777 - Commissioner r, 4”) • • . .a`�oTE IMMIDD/YYYYI ® CERTIFICATE OF LIABILITY INSURANCE DA05/18/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE ROES 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: lithe certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. N 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 DOWLING&O'NEIL INSURANCE AGENCY NPHONE ue.No.Eau: (508)775-1620 WO,„,): EMAIL ADDRESS: jbednark@doins.com 9131YANNOUGH RD INSURER(S)AFFORDING COVERAGE NAIC0 HYANNIS MA 02601 INSURERA: ACE AMERICAN INSURANCE CO 22667 INSURED INSURER S: KELLY ROOFING INC INSURER C: INSURER D: 8 RHINE RD - INSURERE: . YARMOUTHPORT MA 02675 INSURER F: COVERAGES CERTIFICATE NUMBER: 270683 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. INR TYPE OF INSURANCE ADOL SUBR POLICY EFF POLICY EXP LIRINCD WVD POLICY NUMBER IMMIOP/YYYY) IMMIDDIYYYYI LIMITS COMMERCIAL GENERALLIABILITY EACH OCCURRENCE $ CLAIMS-WOEDAMAGE S(Ea occurrence) urr ENT ED fl OCCUR PREMISE TO R $ MED EAP(Any one person) $— — N/A PERSONAL&ADV INJURY $ — GEN'L AGGREGATE LIMIT APPLES PER GENERAL AGGREGATE $ POLICY❑Fla 0 LOC • PRODUCTS-COMP/OP AGO $ OTHER $ AUTOMOBILELIABILITY COMBINEb SINGLE LIMIT $ (Ea accident _ ANY AUTO BODILY INJURY(Per person) $ — ALL OWNED AUTOSSCHEDULED N/A BODILY INJURY Per accident) $ AUTOS _ AUTOS ( ) NON-OWNED PROPERTYGE HIRED AUTOS _ AUTOS (Per scolded) $ $ UMBRELLA LIAROCCUR EACH OCCURRENCE $— — IA EXCESS LR CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X &TANTE OTH- ER AND EMPLOYERS'LIABILITY Y/N AN1'PROPRIETOR/PARTNEIVEIIFCUTIVE wA E L.EACH ACCIDENT $ 500,000 A OFFICER/MEMBERF](CLUOEO? NIA NIA 6562U88H08580918 . 05/10/2018 05/10/2019 (Mandatory ryIn NN) E.L.DISEASE-EAEMPLOYEE $ 500,000 If ea, IPTIONSneer DESCRIPTION OF OPERATIONS Oebw EL DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,AddlSona RAnMEA Schedule,may be Attached If mon space Is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance 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.govAwd/workers-compensatioMnvestigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Lakeville ACCORDANCE WITH THE POLICY PROVISIONS. 346 Bedford Street - AUTHORRPED REPRESENTATIVE Lakeville MA 02347 7)"-t C.t� Daniel M.Cro 9 ey,CPCU,Vice President-Residual Market-WCRIBMA ®1988.2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD . O Y) A CERTIFICATE OF LIABILITY INSURANCE ' DATEIMMLIWYTT 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), ADTHOttIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: H the certificate holder is an ADDmONAL INSURED,the policy(ies)must be endorsed. H 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 CONTACTJoanna Bednark —/ NAME:E: DOWLING&O'NEIL INSURANCE AGENCY PoiHO" E„,,: (508)775-1620 FAX No): ' ADDRESS: jbednark@doins.com , 973 IYANNOUGH RD INSURER(s)AFFORDING COVERAGE :rNAICI 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: YARMOUTHPORT MA 02675 INSURER F: COVERAGES CERTIFICATE NUMBER: 270684 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTRwqD MD POLICY NUMBER (MM/DD/YYYYI IMMIDD/YYYYI COMMERCIAL GENERALLABILTY EACH OCCURRENCE $ DAMACLAIMS-MADE 0 OCCUR PREMISES(Es occO IN I urrence) $ MED EXP(My one porton) $ N/A PERSONALS ADV INJURY $ 'GENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 1I POLICY O.78T D LOC PRODUCTS-COMP/OP AGO $ OTHER' $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) _ ANY AUTO BODILY INJURY(Per person) $ _ • _ ALL OVMED AUTOS .ED WA BODILY INJURY(Petpcddent) $ _ HIREAUTOD AUTOS _ AUTOS ED P((PRo accident))),or' ':. $ :l $ UMBRELLA LIMB OCCUR EACH OCCURRENCE $ EXCESS LAB — MAIMS-MADE N/A AGGREGATE $ DED RETENTION; $ WORKERS COMPENSATION X STATUTE OTH- ET AND EMPLOYERS'LIABILITY Y IN A ICERR/MEiBEERRE<CLLUDEm CUTwA N/A NIA 6S62UB8H08580918 05/10/2018 05/10/2019 E.LEACH ACCIDEM' $ 500,000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 Eyyes,desats under DESCRIPTION OF OPERATIONS below E L.DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,AddllonS Remote Schedule,may to attached If more space Is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 0,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 insurance 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.govfwd/workers-compensationfinvestigationst CERTIFICATE HOLDER CANCELLATION . SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE - THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Falmouth ACCORDANCE WITH THE POLICY PROVISIONS. 59 Town Hall Square - AUTHORIZED REPRESENTATIVE Falmouth MA 02540 L_.•lei C� Daniel M.Croy,CPCU,Vice President—Residual Market—WCRIBMA I ®1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD