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Home My WebLink AboutBLD-19-001148 ,,� :pi•Y9R Office Use Only it �, t. �-. PermiW O "4.,,- - y. Amount 6 re' 'Ir. si..,4' 55:0......... ,...— �y� t ' (/ Permit expires 180 de - -. , . issue dme 61.0—'1Q—CD1ty C \ EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department RECEIVED 1146 Route 28 South Yarmouth,MA 02664 AUG 2 7 2018 (508)398-2231 Ext. 1261 tI ,� f� (1-1.12,1A-12— l/ BUIya' RTMENT CONSTRUCTION ADDRESS: l v \ Syr — -- IF ASSESSOR'S INFORMATION: fMap: I , Parcel: OWNER: i /a eG I N +� VI, -14,Ree� `"t0 p L (44.a.M.Ot rm. d✓.4 CP_bb4 664 1> " PRESENT ADDRESS TEL # CON &WJJ TRACTOR: l 1CaC—N Cr kr-- 475 awAye OD th QMporti P atm 02b7 // NAME MAILING ADDRESS TEL 5o$ So'? /64-1 Of sidential 0 Commercial Est.Cost of Construction S 3500� Home Improvement Contractor Llc.# s-9 51 Construction Supervisor Lie.# Oat 9167 Workman's Compensation Insurance: (check one) 0 I am the homeowner/�/J 0 I e sole proprietor Fri e Worker's Compensation Insurance /�/ ,/ Insurance Company Name: F t S A-€..4,4 Worker's Comp.Policy# 0621,66 I/0 &s2ce WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove • Siding: #of Squares Replacementplwindows:# Replacement doors: # ✓Rooting: #of Squares 10 ( (/)Remove existing*(max.2 layers) Insulation Old Kings Highway/Historict�/ Dist ( )/R�e/placing like for like Pool fencing 'The debris will be disposed of at ti, 4Q.,s,N _ . Location of Facility I declare under penalties of p that the statements herd' o•. are tate and correct to the best of my knowledge and belief. I understand that any false ani will be just came for d on of my icense , ) ion under MIL Ch.268,Section I. �7 / q' Applicant's Signam�0, r J��S�/� Date: is /`� / 1 Owners Sign •re(or a //7...ca._dr Date: Q 1,71,/[[[ ((( /fApproved B . �4� Date: e • 7' Buil.ing s' ' (or..fr - EMAIL ADDRESS: Zoning District: Historical District C Yes 0 No Flood Plain Zone: C Yes C No ' Water Resource Protection District Within 100 ft.of Wetlands: '`. 0Yes 0 N 0Yes 0 No The Commonwealth ofMassadtusetts .52=,=;) ice 1 Department ofIndustrial Accidents 1= 1 Congress Street,Suite 100 %ALE: Boston,MA 02114-2017 •- www.mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMUTING AUTHORITY. Applicant Information Please Print Legibly Name ( ' 'duAal1),: l ATl k l9 U V Gr Address:• ) \ UA � 1 01)-(), City/State/Zip: LI4411p Phone#1: Sdit 09 %• �f Are you an employer?Clack the appropriate box: Type of project(required): 1.0 tem a employer with ( employees(full and/orpart-time).• 7. 0 New construction 2.01 am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required,] 3.❑I am s comR inwaanee required.] homeowner doing all work myself[No workers' t 9. CI Demolition 4.0tam a homeowner and will be hiring contractors to conduct all work on my property. I will 10 ❑Building addition ensure that all contactors either have workers'compensation insurance or we sole 11.0 Electrical repairs or additions proprietors with no emvloYee& 12.❑Plumbing repairs or additions 5.01 am a general contractor and I have hired the sub-contactors listed on the attached sheet 13 hoof repairs These sub-contractors have employees and have workers'comp.insurance 6.0 We are a corporation end its offices have exercised their right ofe exemption per a 14.❑Other ffi 152,41(4),and we have no employees.[No workers'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 Mthe sub-contractors and state whether or not those entities have employees. If the subcontractors have employees,they must provide their workers'comp.policy number. I am an employer that Is providing workers'comApensation insurance for my employees. Below Is the policy and job site information. ��tt ,,� Insurance Company Name: l� -� Q�f"1 Q A-P3 Policy#or Self-ins.Lie.#: &QJJ 1,)'5 V Ixpiration Date: 5 ' (0 ' (1'3.Job Site Address:4/J \,01 ektka.E City/State/Zip: 5D 442-M anlik'z Val Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MOL 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 5250.00 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 h- ist:Vtigthe pains - d pe ;es perjury that the information provided above Is a and correct. Q� Siinature: SC J�e t `- Date: I� ( G (> Phone#: 509 LiJ Offckl 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 ® CERTIFICATE OF LIABILITY INSURANCE DATE(MINDDAYYY) 07272018 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 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,the policy(ies)must be endorsed. If SUBROGATION IS WANED,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 NAME LCT Emily Montgomery DOWLING&O'NEIL INSURANCE AGENCYtAx"x Ertl (506)775-1620 i c.No,: MAIL emont oma doins.com ADDRESS: g ry� 973 IYANNOUGH RD INSURER(S)AFFORDING COVERAGE NAICF HYANNIS MA 02601 INSURER A: ACE AMERICAN INSURANCE CO 22667 INSURED INSURER B: KELLY ROOFING INC INSURER C: INSURER D: B RHINE RD INSURER E YARMOUTHPORT MA 02675 INSURER F: COVERAGES CERTIFICATE NUMBER: 296439 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 ADDL SUER POLICY EFF POUCY EXP UMC LTR INSD wvn POLICY NUMBER (MMND/YYYYI (MMNDIYYYYI COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE f DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ _ N/A PERSONAL 8,ADV INJURY $ ''GGEEINT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ RPOLICY❑78: LOC PRODUCTS-COMP/OP AGG $ OTHER AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT f (Ea acadent) ANY AUTO BODILY INJURY(Per person) $ — ALL OWNED SCHEDULED AUTOS N/A BODILY INJURY(Per accident) $ _ AUTOS NON-OWNED PROPERTY DAMAGE _ HIRED AUTOS _ AUTOS (Per accident) f UMBRELLA UAB _ OCCUR EACH OCCURRENCE S _ EXCESS UAB CLAIMS-MADE N/A AGGREGATE f DED RETENTION$ � p f WORKERS COMPENSATION X PEj_gEA11JTE ERµ AND EMPLOYERS'LIABILITY YIN A OFFICER/MEMBER EXC EXCLUDED? � WA WA N/A 6S62UB8H0858091B 05/10/2018 05/102019 E L EACH ACCIDENT $ 560.000 (Mandatory In NH) E L.DISEASE-EA EMPLOYEE $ 500,000 N vee,desmbe under DESCRIPTION OF OPERATIONS below E L.DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If mon apace Is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 6,no authorization is glen 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-compensationfinvestigations/. • CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Plymouth ACCORDANCE WITH THE POLICY PROVISIONS. 26 Court Street AUTTHORMED REPRESENTATNE Plymouth MA 02360 Daniel .Cro y,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 �1ie Wo ,wncaea4Y o jod Ae f Office of Consumer Affairs and Business Regulation -�'' 10 Park Plaza- Suite 5170 Boston, Massachusetts 02116 . Home Improvement:Contractor Registration MN rt—rt—r: _- =2 r.7 Type: Individual OLIVER KELLY '',' ' ;;,k: ``t t Registration: 128957 8 RHINE RD =_, ;=_ : _- ._,_� ,i• ExpiraUOn: 08/13/2019 • YARMOUTHPORT,MA 02875 ----7—_-:. -1:-:, ;' =_ t,. r i...rE.. Update Address end return card. Mark reason for t Sem a 20M-05111 ' -- — -_ _ . t!A _Q An+s. 1'l O.Ip_�t nWMniovm.nt 0 Lag � c5?ecf orntonrrxa(l4 / fh.uarAtael Office of Consumer Affairs 8 Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only -. TYPE:IndMdual _ ,before the expiration date. If found return to: Registration Exniratlgn Office of Consumer Affairs and Business Regulation 128957._ 06/13/2019 10 Park Plana-Suite 5170 R KELLY ,I , '.:- Boatdd;M 02116 c,.. OUVER M.KELLY _- _ ,�4� �, C . .�. -` 8 RHINE RD. -_ -- U\\\ YARMOUTHPORT,MA 02675Undersecretaip•—. Not valid without signature • • Commonwealth of Massachusetts - Division of Professional Licensure • Board of Building Regulations and Standards • ConstructiodtSUp4h4spr Specialty CSSL-099167 • Ekpires:09/2812019 • • OLIVER M KELLY •`r . If 8 RHINE ROAD, J� . • YARMOUTH PORT MA 02676 _ f#;77 ' rye} r Commissioner Cele "%. a,,,t"t,��