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Home My WebLink AboutBLD-19-001985 - Office Use Only O ' r -4 ''. 40 Permit# p -'4 Amount l/ J - 2. "^+.,00.,L 4P.: Permit expires 180 days from issue date Bt—(Ci -Opt G.0 RECEIVED EXPRESS BUILDING PERMIT APPLICAT TOWN OF YARMOUTH OCT 0 3 2018 * Yarmouth Building Department 1146 Route 28 Bui r , htNT South Yarmouth,MA 02664 _ n (508)1398-2231 Ext. 1261 CONSTRUCTION ADDRESS: G` 21S 6 Y-/``tik... t AU e. 0 r It 4M010,311.4 ASSESSOR'S INFORMATION: Map: Parcel: OWNERJ\V MC eN^`gi vA nikukiLI ? x c j 24. o2q o T NAME PSNpN TEL _ n CONTRACTOR: tka.ty(p... v3C�- 0�1,w)e K -4�� -,�« 't' Suess Scm ti hL1.0 NAME MAILING ADDRESS TEL# 0 Residential 0 CommercialEst.Est Cost of Construction$ SOtYJ Home Improvement Contractor Lia# (1957 Construction Supervisor Lie.# aq.C:i/b7 Workman's Compensation Insurance: (check one) 0 I am the homeowne 0 I the sole proprietor 6Y1 have Worker's Compensation Insurance �J �[,/(7 G p Q/ Insurance Company Name: I)� 1 Worker's Comp.Policy# (JJLUJi/ 0 (10n S�o 1 is' WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate'''ffattached?) Wood Stove Siding: #of Squares Replacement windowsill Replacement doors: # Roofing: #of Squares 14 ( )Remove existing4(max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing ilk for like Pool fencing *The debris will be disposed of at: q4,2,4043)-14P-A.PS Location of Facility I declare under penalties . ' ry that the statemen herein contained : - true . d correct to the best of my knowledge and belief. I understand that any false answer(s) will be just cause for. a tr of my Ii. and for . and M.G.L Ch.268,Section I. t,r� Applicant's Signature a��/ 1 Date: 1 0 0 [ 1 Owners Signa a(or ath omen� lll� � Date: / .t. • p Approved By. e" fie'—' ` Date, e Building Offtci ', ee) EMAIL ADDRESS: Zoning District: Historical District: 0 Yes 72 No Flood Plain Zone: C Yes C No Water Resource Protection District: Within 100 ft.of Wetlands: C Yes 0 No 0 Yes C No The Commonwealth of Massadhusetts • .,Ma-, � !t Department oflndustrialAccidents _.i,Rl' I Congress Street,Suite 100 `SDI � Boston,MA 02114-2017 `�:. ,,r" www.massgov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information � � /� � � � Please Print Legibly Name usin O n dual):} �J�,[,��( Address ��/1r'VT'd � City/State/Zip: 'IA2.MtkQOi,( 01- CgOSPhone#: S Lc 509 116 go Are you an employer?Check the appropriate bor. Type of project(required): 1.01 am s employer with l employees(fuli and/or part-time).* 7. 0 New construction 2.01 am a sole proprietor or partnership and have no employees waldng forme in capacity.[No workers8. 0 Remodeling any '�R insurance required.] 3.0 I am a homeowner doing all work myself[No workers•�R insurance required]r 9• Demolition❑ 4.0 I am a homeowner and coal be hiring contractors to conduct as work on my property. I what 10 0 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions pmprietors with no employees. 12.0 Plumbing repairs or additions 5.QITt Ihave hueedthe sub.mattached 13. f sus employes and hoe workers'comp.mswauce.rrepairs 6.0 We are a corporation and t officers have exercisedtheir right of cwapton pa MG.e 14.0 Other 152,§1(4),and we have no employees.[No workers'cowry.insurance required.] 'Any applicant that chech bot#1 mast also 511 out the section below showing their workers'compensation policy indbntnation. t Homeowners who submit this affidavit indicating they am doing all work and then hire outside cov6acmns must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub-cortractotsendsuraewhetherornotthoseentitieshave employees lithe sub•wutrazxors have employees,they most provide their worken'comp.policy numbs Iant mr employer that is providingworkers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Actc / MJ h Le,,4-{J Policy#or Self-ins. ic.#: `05(j2Uq2 �I j 5cce.S5 expiration Date`: 6 '' (0 q Job Site Address: ( kC, 4 t tU W City/State/Zip:W I, °Aim 02b73 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. _ I do h- • , a• n- the pain s(mrd p perjhry that the information provided above is • e and correct .00 SiM e: ie S ti ate: to 0 one#: dr: i tgy Y. Official use only. Do not write in this area,to be completed by city or town offreiaL 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 it: • A�® CERTIFICATE OF LIABILITY INSURANCE DATE(MWDD/YYY1) • 09202018 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 L NAME; inda Sullivan DOWLING&O'NEIL INSURANCE AGENCY PHONE o EMI' (508)7751620 (A/C.No): AMAIL DDRRESS: Issullivan@doins.com 973 IYANNOUGH RD INSURERS)AFFORDING COVERAGE NAIC HYANNIS MA 02601 INSURER A: ACE AMERICAN INSURANCE CO 22667 INSURED INSURER B: KELLY ROOFING INC INSURER Cr INSURER D 8 RHINE RD INSURER E: YARMOUTHPORT MA 02675 INSURER F: COVERAGES CERTIFICATE NUMBER: 316737 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 SUBR POLICY EFF POLICY EXP LIMITS LTRINSO,WYD POLICY NUMBER (MWDD/YTYY1 (MMNdYYYYI COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S DAMAGE r0 RENTED CLAIMS-MADE D OCCUR PREMISES(Ea occurrence) S MED EXP(Any one person) $ _ N/A PERSONAL ADV INJURY $ GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ RPOLICY D jECT LOC PRODUCTS-COMP/OP AGO $ OTHER' S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S IEa taMentl ANY AUTO BODILY INJURY(Per person) $ _ ALL OWNED SCHEDULED N/A BODILY INJURY(Per accident) $ _ AUTOS AUTOS N- -OWNED PROPERTY DAMAGE _ HIRED AUTOS _ AUTOS (Per ecadent) S UMBRELLA LIAB _ OCCUR EACH OCCURRENCE _ S EXCESS UAB CLAIMS-MADE N/A AGGREGATE S DED RETENTION$ S WORKERS COMPENSATION X STATUTE ETH AND EMPLOYERS'LIABILITY A OFFICEORJMEMBEREXCLUDEpEL EACH ACCIDENT S 500,000 gXECVTIVE WA WA WA 6S62UB8H08580918 05/10/2018 05/102019 (Mandatory In NH) E.L.DISEASE•EA EMPLOYEE $ 500,000 II yes,descnbs under DESCRIPTION OF OPERATIONS below E L DISEASE•POLICY LIMB $ 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached N more space Is mgWred) 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/workerscompensation/lnvestigatlons/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN David Bernstein Builders ACCORDANCE WITH THE POLICY PROVISIONS. 139 Nantucket Drive AUTHORIZED REPRESENTATIVE Chatham MA 02633 L Daniel 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 • • '� -.-_-- LJ �"GU Wt'YI�7//'/Zoinef iWI�///'G Q/C_��'6madete eeZ --- Office of Consumer Affairs and Business Regulation 10 Park Plaza- Suite 5170 Boston, Massachusetts 02116 Home Improvement:Contractor Registration _: _m_ CO Type: Individual Registration: 128957 S KELLY ':, -'' :- 1 ='= it, lration: 06/13/2019 8 RHINE RD hen .,__. r;:_;; =��i�, E>4� ' YARMOUTHPORT,MA 02675 ' ( 1:-..=5 ii, 1. i - - _=K'1 .5 (i\ -ic_ /^ri Update Address and return card. Mark reason for ch SCA1 0 20M05111 ----- __Q[�? __ A dMp rl&Tana n Fmr11Lown.nt CI Lem t • �e St;mmentreXwlfA oit ifor:taeArorcm - - OMP of Consumer Affairs a Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYPE:Individual . before the expiration date. If found return to: __Recletmtlon E7miratloq Office of Consumer Affairs and Business Regulation ?":1.28957 08/13/2019 10 Perk Reza-Suite 5170 RIa=LLY Bostdn;M 02118 /JP CL)--..e. OUVER M.KELLY 2_C�.p� ----17.----4 1i....._.. 8 RHINE RD. " - ! YARMOUTHPORT,MA 02875 Undersecretary Not valid without signature • • Commonwealth of Massachusetts ®, Division of Professional Licensure • Board of Building Regulations and Standards Con structiort ,Shpem4spr Specialty . CSS L-099167 I Expires:09/26/2019 • OLNER M KELLY —4 4 ;•' II RHINE ROAD, 1:11,1t)-161"-. • YARMOUTH PORT MA 028761_ ' 'CS.x1;C': . Commissioner 1'� "`" `'i • • 7 r ) . .