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Home My WebLink AboutBLD-19-001706 Once Use Only OF'Y`IR •Z p Permitil e O "b.+ Amount 1/4" w *r r 4'"'°"' S �ermrt expires 180 days from �'1 I t� I q I''1�v r.date I-{/ RECEIVEDPP EXPRESS BUILDING PERMIT APPLICATII TOWN OF YARMOUTH SEP 20 2018 ` Yarmouth Building Department 1146 Route 28 8U • TA/ �f tM�r�T South Yarmouth,MA 02664 By: 1p(�`-� (508)9,8-2231 Ext. 1261 CONSTRUCTION ADDRESS: ` �ta�L.I .rj S tJt2_ SJQI.{ `I4 M GSM ASSESSOR'S INFORMATION: Map: Parcel: OWNER: Sue l slog; H. AthtotA I,A4 • ` l �1 724 470 Sf 46 NAME vac,- PRE )) T ADDRES /(J� TEL # CONTRACTOR: 'tet LA pat W� I�•L1✓J e ....10A4) t�Qp_r SCS S -i L1 LL Q NAME MAILING ADDRESS TEL# 0 Residential 0 Commerrcciaall Est.Cost of Construction$61000 Home Improvement Contractor Lie.# /.,L(194-7 Construction Supervisor Lie.# oq.9/b7 Workman's Compensation Insurance: (check one) 0 I aril the homeown0Ct 0 I the sole proprietor WI have Worker's Compensation Insurance �J /� 2 t , G Insurance Company Name: 1(',q. Worker's Comp.Policy# (JJI�[t_J(� W O`�J S75.03 18' WORK TO BE PERFORMED• Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement/ windows:# Replacement doors: # Roofing: #of Squares lei ( �( )Remove existing*(max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing Ilkg�fo�r like� 5� Pool fencing "The debris will be disposed of at: q ..,/�1©�lr� 11*P-- ASA 9° — 1111 Location of Facility I declare under penalties • :. ' ry that the statemen herein contained a true: d correct to the best of my knowledge and belief. I understand that any false answer(s) will be just cause for• alai o • of my Ii and fore . un. r M.G.L Ch.268,Section t. 720/ IApplicant's Signature: jillir i/' ' .A Date: 1 l 3Owners Signature(or attachment) Date: �'` �7� Approved By: �� Date: /"'- o-ye Building 0 (or gnee) EMAIL AD V1 S: Zoning District: Historical District: 0 Yes :: No Flood Plain Zone: 0 Yes C No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes J No 0 Yes C No ' . The Commonwealth of Massachusetts ' _�, i='/ Department oflndustrialAccidents - wt.= a 1 Congress Street,Suite 100' _ • rag Boston,MA 02114-2017 '+v.,r' www.mass.gov/dia Workers'Compensation Insurance Affidavit Builders/Contractors/Electrlclans/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. ,thAlteant Information Please Print Legibly Name(Busine O o ndividual): V - G Address:• V( O, i5� u City/State/Zip: titVM ego/ Phone#: Soli .. W9 1-th e/o • Are you as employer?Check the appropriate box. Type of project(required): 1.0 I am a employer ant' It employees(tug and/or part-time).* 7. 0 New construction 2.01 am a sole proprietor orparmership and have no employees working for me in 8. 0 Remodeling any any.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all wcemp insurance required] work myself(No workers' t 9. ❑Demolition 4.01 am a homeowner amdail ba hiring contractosto conduct all work on my property. I will 10 0 Building addition ensure that all contractors either have workers'compensation insurance or ere sole 11.0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.01 am a mend contractor and I have hired the subcontractors listed on the attached sheet 13. oof repairs These sub-contactors have employees and have workers'comp.insurance.: 6.0 We em a corporation and its officers have exercised their right of exemption per MGL e. 14.0 Other 152,11(4),and we have no employees.(No workers'comp,insurance required] •Army applicamthat checks box#1 must also fill out the section below showing theirworkera'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then him outside contractors must submit a new affidavit indicating such. :Cormecmn that check this box must attached an additional sheet showing the name of the sub-cotractots and state whether or not those entities have employees. If the sotHsontactom have employees,they must provide their workers'amp.policy nut. I am an employer that is providing workers'compensation buurancefor my employees. Below is the policy and job site information. Insurance Company Name: At cfr: 1^f,As: Q, 0,4E3 Policy#or Self-ins..Lia#•1, 6-)22...)6-)22...) j�fl�j 5 V�'[� xp on Date: 5 ' (Q ` l Job Site Address:3 �f�, LU?? t • Crit r III 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 DIA for insurance coverage verification. Ido her . the pains • d p , .es . perjury that the information provided above is a and correfi Signature: •► �a & a.-- Date: 9 /20 ( G 8d Phone#: 50% 509 . I 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#: Commonwealth of Massachusetts intDivision of Professional Licensure Board of Building Regulations and Standards Constructiot)S'lp&ivisor Specialty CSSL-099167 �1 Expires:09128/2019 .- , OLIVER NI KELLY " 1 , 8 RHINE ROAD, sA T YARMOUTH PORT MA 02675 "t - t t cmissioner omr{ Q9 e �po/:rvonowalea ott Atme, Office of Consumer Affairs and Business Regulation 10 Park Plaza- Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Type: Individual s.t i -==.-'r=;;:;'.:__ _i _r;, Registration: 128957 OUVE8 RHINE KELLY s l l'r Expiration: 06/13/2019 BRHINERD _-= is+- — Fr'` YARMOUTHPORT,MA 02675 "i "" _..` 'i Update Address and return card. Mark reason for change. SCA1 O 20M-05/11 _�._.__l, Addrwao f'14.neml rT PnlnlovmaM 17 Lott Card.... ... !//e ,1umrier/v.7N n/b/(iiiNir'iuirfa a] Office of Consumer Affairs&Business Regulation i �3 HOME IMPROVEMENT CONTRACTOR Registrationreiration individual If found return to: 4i, TYPE:Individual AealstretioR Expiration Office of Consumer Affairs and Business Regulation R q 10 Park Plaza-Suite 5170 ,„�» W _ �% _ - . 128957_ 06/13/2019 _ '� +�i,y.,: _ - Boston;MA 02116 ^1 O VER ILLY ` - ) e OLIVER M.KELLY '�LCC—p'"i P Lira,- --4 --=1 w'"= 8 RHINE RD. - - un Not valid without signature t, YARMOUTHPORT,MA 02675 Undersecretary'._ 1, KELLY ROOFING PH. 508 509 4640 8 RHINE ROAD MA C.S.L.#099167 YARMOUTHPORT MA H.I.C.R.#128957 MA 02675 INSURED August 14' 2018 Proposal submitted to Susan Lyons of 3 Phyllis Drive South 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. 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, but are not limited to, Certainteed products,This quote is based on the Basic Limited Lifetime Warranty Landmark Shingle. Replace plumbing vent pipe boots with new. Repair/Replace all flashings as necessary. Install Certainteed Filtered Ridge Vent on all ridges with hand nailed caps. Complete Clean up off all areas including all gutters and all nails after project complete At a total cost of$6,800 Payment Schedule; Balance upon Completion Proposal Submitted by: Oliver Kelly Proposal accepted by: J . �,, e• �� Date. 2 / _d/2018 This proposal is valid for 45 days from date above, please • call to verify thereafter. Best Contact Phone Number: -7 7 y yea sista • 'Acorns, CERTIFICATE OF LIABILITY INSURANCE DATEmmMIDDIYYY • 05/18/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.TI CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICI BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZ 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 the terns and conditions of the policy,certain policies may require en endorsement. A statement on this certificate does not confer rights to 1 certificate holder In lieu of such endorsement(s). PRODUCER CONTACT NAME: Joanna Bedllark DOWLING&O'NEIL INSURANCE AGENCY °Nwc°"ne E+D: (506)775-1620 FAX WC.No): ADDRESS: jbednark@doins.com 973 IYANNOUGH RD • INSURER(S)AFFORDING COVERAGE NAIC HYANNIS • MA 02601 INSURERA: ACE AMERICAN INSURANCE CO 226E INJURED INSURER B: KELLY ROOFING INC INSURER C: • • INSURER D: 8 RHINE RD INSURERS: 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 PERI INDICATED. NOTWITHSTANDING ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH T CERTIFICATE MAY BE ISSUED OR MAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERI EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.L(MRS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. !NSR ADOL'SUER POLICY EFF POLICY EXP LTR TYPE CF INSURANCE NqD PIVD POLICY NUMBER MIMIOO(yYYYI IMMAIDIYYYY1 UNITS COMMERCU1LGENERALU1BRrY - EACH OCCURRENCE ° $ CIA/MS-WIDE MADE ❑OCCUR DAMAGE S(EO occurrence) U PREMISES RNILE E MED bm(Any one person) $ N/A PERSONALS ADV INJURY $ GENL AGGREGATE LIMIT APPLES PER GENERAL AGGREGATE $ POLICYn Ea o L PRODUCTS-COM%OPAGG $ OTHER: 4 E ., AUTOMOBILEUASIUTY COMBINED SINGLE LIMT E (Ea accideel) ANY AUTO BODILY INJURY(Par person) $ ALL OWNED SCIEOIA® AUTOS AUTOS NIA BODILY INJUr(Por accident) $ _ NU HIRED AUTOS _ AUTOS PROPERTYeraccident) GE E UMBREWLIAB _ OCCUR EACH OCCURRENCE E EXCESS LIAB CLAIMS-MADE N/A AGGFEGATE E DEO RETENTIONS $ WORKERS COMPENSATION �/ PER OTH- AND EMPLOYERS'LIABWTY X STATUTE ER Y/N ANYIROPRETOR/PARTNEfi/E%ECUTIVE E.L EACH ACCIDENT E 500,000 A OFFICE AABABFFEXCLUDED? WA WA WA 6S62UB8H08580918 05/10/2018 05/10/2019 - (TAUldelorylnNl) E.L DISEASE-EA EMPLOYEE $ 500,000 Oyet tleeODN OF O DESCRIPTION OF rPERATTONS bebvi E.L.DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS!LOCATIONS 1 VEHICLES(ACORD 101.Adeleons Remarks Schedule.may he attached It mora apace N 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 t 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.masa.govtlwdlworkers-compensationfinvestigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFC THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED Town of Falmouth ACCORDANCE WITH THE POLICY PROVISIONS. 59 Town Hall Square AUTHORIZED REPRESENTATIVE Falmouth MA 02540 D-c C� Daniel M.(ktv y,CPCU,Vice President—Residual Market—WCRIBM, 01988.2014 ACORD CORPORATION. All rights rese ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD