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Home My WebLink AboutBLD-19-002296 y s.Office Use Only • 'of. AR 4 •.k w- t: t C;. .. n Permit" ,^4-.." .� + ___e,9‘-c,,,,,„,,,. g Permit expires 180 days from . issue date /� to Comb-lq—bD22A to EXPRESS BUILDING PERMIT APPLICA±IOI C E 1 V E= D • TOWN OF YARMOUTH LOCT Yarmouth Building Department 18 2018 1146 Route 28 South Yarmouth, MA 02664 Buie ir .�� T (508) 398-2231 Ext. 1261 By _/ , 14,-noti7 `�_CONSTRUCTION ADDRESS: Z7 (it/,,,,-. 9�Mnic (,N £ - ASSESSOR'S INFORMATION: Map: Parcel: OWNER: efrptCt / 4E-roc Z7TifI / X6-4 IA) c `, _ 461Lor (DS266c,6c , NAME PRES SS CONTRACTOR ku J te n4�/- g e- r � 01IA vDS 1c MAILING ADDRESS TEL YIg 9 Q'&Ile esidential 0 Commercial �q �7 . Est Cost of Construction$gpC Home Improvement Contractor Lia# /22 5 / Construction Supervisor Lie.# C99t47 Workman's Compensation Insurance: (check one) 0 I am the homeown40c 0 IZatleAzij e sole proprietor 0 I have Worker's Compensation Insurance A ,/ r/t(+/ /1/ Insonate Company Name: Worker's Comp.Policy#/3$6?V/7 P/08- U&9( WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: '#of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing 'The debris will be disposed of C 14-0.-K0-4.7tilk - t/gl�fJ 5_P- -5.8� Location of Facility I declare under penalties of perjury that the statements herein contain 'true and correct to the best of my Imowledge and belief I understand that any false answer(s) will be just cause for. . . A on of my license an or pm cutis under M.G.L.Ch.268,Section 1. �1, Applicant's Sign.. .r e 4 / Date: 10 . i'lS s l iS Owners Signature(or attachment) ((aMA -S Pell ler Date: 10 eIg IF Approved By: `%��) Date: Al�� 6 B al(or desigtree) ADDRESS: Zoning District Historical District 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: ' ❑ Yes ❑ No ❑ Yes 0 No • / ✓ The Commonwealth of Massachusetts Department of IndustrialAccidents 1 Congress Street, Suite 100 • Boston, MA 02114-2017 • tOrir wwwarzass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH TEE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Orggizatiion/,Individ al): tLeL ( ��W c- Address: '2 U,uJ a Q�() City/State/ZipSA ° "k pptmoss Phone#: 6g So' Lib L1O Are you an employer?Check the appropriate box: Type of project(required): I. I am a employer with ( employees(full and/or part-time).• 7. ❑New construction 2.❑1 am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling • any capacity.(No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself[No workers'comp.insurance required.]t 9. ❑Demolition 4.❑I am a homeowner and will be hiring contactors to conduct all work on my property. I will 10 ❑Building addition ensure that all contactors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions • proprietors with no employes, 12.❑Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contactors listed on the attached sheet These subcontractors have employees and have workers'comp.insurance.: 13. Of repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),artd 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 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 subcontractors have employees,they must provide their workers'comp.policy number. I am an employer that is proving workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: ci Policy#or Self-ins.Lic.#: 165(02 v %t40%S%OILS Expiration D$$,' 0 �1 W Job Site Address:21 V.?&'Sri-AAs L (Aj City/State/Zip: tl a.n4A,--1."•. 02b6ti 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 hereb ' under the pains • d,:.;,alties of perjury that the information provided above is true and correct. Sign 4111 Date: tO Phone#: sog sod (it) n 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#: s- VG92P GL7 YG0/J?�LI1�'f� e/P. !%LCL'QJ'Cz(i��GG -= e�f Office of Consumer Affairs and Business Regulation =-4`` u 10 Park Plaza• Suite 5170 Boston, Massa setts 02116 Home Improvement Co ctor Registration 'ti ,— Type: Individual I i..�n —— r Registration: 128957 OLIVER KELLY • zr'- —' F ii Expiration: 06/13/2019 8 RHINE RD J (l—r�'�`-^,tl�__ • YARMOUTHPORT,MA 02675j.1 •1_ ii c v � �r , w. • :___;-:7 Update Address and return card. Mark reason for change. SCM 0 20M-05/11 ._ ��_�...�p_��...__.._-..._J/ _ naciertwne rl t7e vy.& nFn1nl[1am7snt 0 Last Card • L."":\ c lee o ni neonvvraf/Ao/o1ZJSar4uie//1 —.—Y_'l.. • Office of Consumer Affairs a Business Regulation HOME IMPROVEMENT CONTRACTOR - Registration valid for Individual use only TYPE:IndMdual before the expiration date. R found return to: . Feaistraton Expiration Office of Consumer Affairs and Business Regulation • 128957 06/132019 10 Park Plaza-Suite 5170 O VER KELLYTI ` Boston M 02116 V....... g,. OUVER M KELLY ' U .� �y, ' 8 RHINE RD i'� 755st VARMOUTHPORT MA 0267Undersecretary, Not valid without signature Commonwealth of Massachusetts ®j Division of Professional Licensure Board of Building Regulations and Standards Con structioQ,S iptiGtspr Specialty CSSL-099167it E,x ires: 09/28/2019 1�a '.,j' 2 OLNER M KELLY r / ry 0 6 RHINE ROAD, ✓ 11 . YARMOUTH PORT MA 02676 s.*�' fit. , t y 1 • I Commissioner .1e„% .+�"`+.:tJ ACERTIFICATE OF LIABILITY INSURANCE DATE (M Y) 09/20/2018 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), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: M 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: Linda Sullivan DOWLING &O'NEIL INSURANCE AGENCY °NAS°"„fin. (508)775-1620 (/C. No): ADDRESS: Isullivan@doins.com 973 IYANNOUGH RD INSURER(S)AFFORDING COVERAGE NMCC 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: YARMOUTH PORT 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 ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INgo wyn POLICY NUMBER (MWDD'YYYY1 (MWDdYYYY) UNITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE ❑OCCUR PREMISES(Es ocmrancel S MED EXP(Any one person) $ — _ N/A PERSONAL a ADV INJURY $ GENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PROJEC- LOC PRODUCTS-COMPIOP AGO $— — OTHER: $ AUTOMOBILE LABILITY • COMBINED SINGLE LIMIT $ Me accident) _ ANY AUTO • BODILY INJURY(Per person) $ — AOWNED SCHEDULED AUTOS N/A BODILY INJURY(Per accident) S _ AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS _ AUTOS (Per accident) _ $ UMBRELLA UAB _ OCCUR EACH OCCURRENCE - $ EXCESS UAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ S WORKERS COMPENSATION X STATUTE ETµ AND EMPLOYERS'LIABILITY ANYPROPRIETORIPARTNERIEXECIJTIVE Y/" E.L EACH ACCIDENT $ 500,000 A OFFICER/MEMBER EXCLUDED? WA WA WA 6S62UB8H08580918 05/10/2018 05/10/2019 (Mandatory In NH) E.L DISEASE-EA EMPLOYEES 500,000 p describe under DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT S 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,AddpbrW Remarks Schedule,may be Cached If noes aped M 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.govftwd/workers-compensatlonlinvestlgationsL 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 I 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 • /