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'OF•y11R • Office Use Only • 4:4 s,,. ! 4'0 Permit# _N�•.�. • it .44 Amount Permit expires 180 da: issue date ttdblG bbl ILK EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department • 1146 Route 28 South Yarmouth,MA 02664 Q �� (508)3�9r8-22 1 Ext. 1261 \ CONSTRUCTION ADDRESS: bs WBbEQ.J '9 �nl 44-Q-MOIrli ASSESSOR'S INFORMATION: n,, \ Map: I_ 1 \ Parcel: 2 OWNER:2.05e- 4ôa DLJ b6 \nl t �os P O7_�7 3NAME..JJ PRESENT fAn�D�D� RESS�- ../n�-- . /44aivtgYrti/ TEL # CONTRACTOR: -A l Cr t at 96 1 e Co 411 -Matin{Paas MA 0261 NAME MAILING ADDRESS TEL# SoS So Eby 01 sidential 0 Commercial Est.Cost of Construction S 6500 Home Improvement Contractor Lie.# In q 6 7 Construction Supervisor Ltc.# O°,916 7 Workman's Compensation Insurance: (check one) 0 I am the homeowner ❑ IZIFt e sole proprieltor,/ I have Worker's Compensation Insurance/ , ,2 Insurance Company Name: �� 1C 4. v Worker's Comp.Policy# 6.6!U66t/o &5so5 WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove • Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares l 1cd ( )Remove existing*(max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing • 'The debris will be disposed of at (+la *1 �Q-0%(V SP-g _ Location of Facility I declare under penalties of perjury that the statements herein contained e and correct to the best of my knowledge and belief. I understand that any false ani will be just cause for den': •r rev. 'on of my li nse and for t der M.O.L Ch.268,Section 1. Applicant's Signatu gillibee S Date: v /21 / u 1 Ie Owners Signa (or attar meat) ' 1.- • ce-- \" Date: '771i /8" Approved By: C I�r - Date: 7• ' Building Official(. •est_ ee) EMAIL ADDRESS: Zoning District Historical District 0 Yes 0 No Flood Plain Zone•. C Yes C No ' Water Resource Protection District: Within 100 ft.of Wetlands: • 0 Yes 0 No 0 Yes 0 No • • The Commonwealth of Massadhusetts e_. Vii_gt Department of industrialAccidents t =_Fang 1 Congress Street,Suite 100 ='ilii_ " Boston,MA 0211¢2017 `4,,i,,:>� www.mass.gov/die. \Yorkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information kU5( ,, Please Prnt Legibly Name(Bruin O • idea!): I,23:L U ) G-- Address: Address: t�an�z �F—VU1&)t 0A-Qi City/State/Zip: A t/t4,0tYSociSPhone#: 09 %g© Are you aa employer?Cheek the appropriate box: Type of project(required): 1.0 I am a employer with 1 employees(full and/or pan-time)" 7. 0 New construction 2.0I am a sole proprietor or partnership and have no employees working for mem any capacity.[No workers'comp.insurance tego;red.l 8. ❑Remodeling 3.0 I am a homeowner doing all work myself[No workers' insurance t 9. ❑Demolition camp ' require:1J 4.0 1 am a homeowner and will be hiring contactors to conduct all work on my property. 1 will 10 ❑Building addition ensure that all contactors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contactors listed on the attached sheet 13 t0 dmf repairs These sub-eonturcton have employees and have workers'comp.insurance.* 6.0 We are a corporation and its officers have exercised their right of exemption perMOt c. I4.❑Other 152,11(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box P1 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. lithe sub-contaaors 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 andJob site information. Insurance Company Name: A CIS IMF. 11(0,M3 (� Policy#or Self-inss Lie.#: 'Q5 W &n2v� �f 5 6 iration Date: 5 ' 10 ' lg Job Site Address: lr)6 r- Sbt QS A- City/StatdZip:��J�.OU ti{ 02-(01-3Attach a copy of the workers'compensation policy deciarati n 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 DIA for insurance coverage verification. Ido here, , : e• . the pains , d p , , . . perjury that the information providedan above is a d corSed Signature:I S 0_ -sir" _ -L-7� l CT Phone#: �� 509 . Official use only. Do not write in this area,to be completed by dry or town official City or Ton: 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#: ` 9:72,e $7exin//noitLGkt Q/�.!t,addaoAuoea / \VI Office of Consumer Affairs and Business Regulation 10 Park Plaza- Suite 5170 Boston, Massachusetts 02116 Home Improvefri.Ement-Contractor Registration :- - = -n Type: Individual • ___.. -,ti'",===.71(-\_1, Registration: 128957 OLIVER KELLY -4.1::.• -, . , 4,,, �.ic, Expiration: 06/13/2019 8RHINE RD •f _.: :" ;�_it,V • YARMOUTHPORT,MA 02675 i' 'LT- t::-..::::;:.-7.:- ' ' ' iy -1/'� Update Address and return card. Mark reason for cls SCAt 0 2OM-05r11 '+ . . ..___�f Ad&!! fl O!nN_ X41 n rmliONne ' a Lr� ca UOin,no,,wcwfa 070&iiadalela . Office of Consumer Affairs a Business Regulation rtHOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only • TYPE:Individual . before the expiration date. If found return to: _- -Rgglstrettort FJtylratlort OMee10 rk ofP ConsumerAffalrsSue and Business Regulation 128957. 06/1312079 Polaza- lt5170 R KELLY•,'I;a::::;--- - - BostdreM 02116 Le "-f ^ ��r, —OLNER M.KELLY _ ...���..�, 8 RHINE RD. YARMOUTHPORT,MA 02675 Undersecretary Not valid without signature F. • Commonwealth of Massachusetts , Division of Professional Licensure • Board of Building Regulations and Standards • Construction-SU0r- spr Specialty CSSL-099167 - Expires:09/28/2019 - - , J st. OLNER M KELLY "f i = 8 RHINE ROAD, • YARMOUTH PORT MA 02676 f�,. 1� �_ T; •I.��.>: r (, • CIA Commissioner �„ 4" a, re II,� . • KELLY ROOFING PH. 508 509 4640 8 Rhine Road MA C.S.L#099167 Yarmouthport MA H.I.C.R.# 128957 MA 02675 July 15 2018 Proposal submitted to Rosemary Morrow of 65 Webber's Path West Yarmouth MA. We propose to supply all materials and labor required to remove and replace the existing asphalt roof at the address above Protect all walls, Windows, shrubs, plants etc. during roof strip. • All debris to be removed to town transfer. 8"White Aluminum Drip Edge to be installed on all eaves. Ice and Water damage protection membrane to be installed on first Six feet of all eaves and around all protrusions. 1' Remainder of roof deck to be covered with synthetic underlayment.. • Install limited lifetime warranty Architect style Shingles, color to be specified, All shingles to be storm nailed (6) • We generally use Certainteed products,this proposal is based on their Standard Landmark Limited lifetime warranty shingles. Replace plumbing vent pipe boots with new. Repair/Replace all flashings as necessary Install Shingle Vent II ridge vent with hand nailed caps. Complete Clean up off all areas including all gutters and all nails after project complete At a total cost of$6500 Kelly Roofing matches the upfront Certainteed product warranty of ten years With a Ten year workmanship Warranty. Proposal Submitted by:Oliver Kelly Proposal accepted by: qJ . i Date./42. 018 �L�.Q� This proposal is valid for 45 days from d e ove please P P Y � . Call to verify thereafter. 7,CriOS6 t A�® CERTIFICATE OF LIABILITY INSURANCE DAo7n7/2018 DD/YY 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; Emily Montgomery DOWLING &O'NEIL INSURANCE AGENCY PHONE gel: (508)775-1620 FAX WC.No): ADDRESS: emontgomery©doins.com 973 IYANNOUGH RD INSURER(S)AFFORDING COVERAGE NAICI 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 INSURERF: 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 OFINSURANCE ADDL SUER POLICY EFF POLICY EXP LIMITS LTRINSD WVO POLICY NUMBER (MWDD/YYYY) (MMNGMYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE El OCCUR PREMISES(Es occurrence) $ MED EXP(Any one person) $ - _— N/A PERSONAL&ADV INJURY $ _ GEM.AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ R — POLICY❑jECT 0 LOC PRODUCTS-COMP/OP AGO $ OTHER $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accden0 ANY AUTO BODILY INJURY(Per person) $ — AOOWNEDSCHEDULED AUTOS N/A BODILY INJURY(Per accident) $ — ,_ AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS _ AUTOS (Per accldeM) _ $ UMBRELLA UAB _ OCCUREACH OCCURRENCE $ EXCESS LMB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY ^ STATUTE ERµ ANYPROPRIETOR/PARTNER/EXECUTIVE Y/N E L.EACH ACCIDENT $ 500,000 A OFFICER/MEMBEREXCLUDED'1 II WA WA 6S62UB8H08580918 05/10/2018 05/10/2019 (Mardemry In NH) E L DISEASE-EA EMPLOYEE $ 500,000 r deeme,ader DESCRIPTION OF OPERATIONS below EL.DISEASE.POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached N more 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.gov/Iwd/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 Plymouth ACCORDANCE WITH THE POLICY PROVISIONS. 26 Court Street AUTHORIZED�' REPRESENTATIVE Plymouth MA 02360 I Daniel n M.Cr , y,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