The URL can be used to link to this page

Home My WebLink AboutBLD-18-002239 ,Ot.,y 1OfficeUse Only fle >*- Pentad/ '� % IPerm O ka w1 ;Amount SO.-- 3% ,Y. Permit expires ISO days from . 8 Cb--I4- af3 3 y l issue date EXPRESS BUILDING PERMIT APPLICA4 C E I V E D TOWN OF YARMOUTH Yarmouth Building Department OCT 1 0018 1146 Route 28 South Yarmouth,MA 02664 'toe lb e ErN T C (508)398-2231 Ext1261 C0fUCnoN ADDRESS: fl glA 6 eA Clk. tAI l\ • ciIMI .Q )ti{ /44 OX9n3 ASSESSOR'S INFORMATION: L Map: Parcel: oW�t 0 t_ enA-1•3 S7 IL «, L).a. t ,, 024 2 NplE PRESENT ADDRESS TEL # CONIRACfOR: k,+J(r We, % aa.1a,i.1k 115 tizatta.YrIktivk 02615 / NAME MAILING ADDRESS *SCA(509 et 61(.0 fE Residential ❑Commercial Est.Cost of Construction S 15,9°Hose Improvement Contractor Lie.# L1 v'tG1 Construction Supervisor Lie.# (AS 167 Workman's Compensation Insurancc (check one) C I am the home° {f❑ I the sole proprietor 0 I have Worker's Compensation Insurance 1 '.,, v� Instamrce CompaoyName f \W � f?U Worker's Comp.Policy/i65(01061 KV�SS 1 O WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #ofofSquares Replacement windows:# Replacement doors: #Y #of RoofingSquares 2.1 ( villtemove existing'(max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )/Replacing like/forrllipke Pool fencing 'The debris will be disposed of at t&( M,Q.4. `TLc t, 1. t _tta V-- London of Facility I declare under penalties of that the statements herein '. .' ed are hve mid comma to the best of my knowledge and belief. I tmderstand that any false answers) will be just cause for d�_ on of , license:... cution under M.G.L Ch.268.Section I. Q� 18' Applicant's Signature: ♦^ Date: �(� Owners Signature(or attachment) - 6!A.,/ j '1_ Date: LLL111� r dApprovedBr• , ��. . Datr. IV — 16" 10Building Official(or designee) DDRESS: Zoning District Historical District: 0 Yes ❑ No Flood Plain Zone: 0 Yes ❑ No Water Resource Protection District Within 100 ft of Wetlands: 0 Yes 0 No 0 Yes 0 No The Commonwealth of Massadhusetts 4 'e f-Tr-n Department oflndustrlalAccidents Congress Street,Suite E AI I • c " 1 Boston,MA 02114-2017 100 :,,, ,,4r$ www.mass gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. tloolicant Information Please Print Legibly Name(Busines o dividuak): kQc l G-- Address: Lir GUAt015� Q-Q City/State/Zip: 41/ AC2 I Phone#: g 09 1-716110 Are you an employer?Cheek the appropriate box: Type of project(required): 1.01 em a employer with 1 employees(fug and/or part-time). 2.01 am a sole 7. ❑New construction proprietor partnership and have no employees working for me in Remodeling8. any capacity.[No workers'comp.insurance required.] ❑ 3.01 am a homeowner doing all work myself[No workers'coinp insurance required.]t 9. El Demolition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. 1 will 10 ET Building addition ensure that all contractors 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 ralSof repairs These sub-contractors have employees and have workers'comp.insurance. 6.0 We are a corporation and m officers have exercised their right of exemption per MGL e. 14.❑Other 152,41(4).and we have no employees.[No workers'comp.insurance required] *Any applicant that checks bot#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. ;Contactors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether ornot those entities have employees. If the so-contractors have employees,they must provide their workers'kers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information, ��t ,�- n \ Insurance Company Name: 4 LFA i/ 11A A 1=((Q,�(--(33 Policy#or Self-ins.Lia#: (co� (h2L,)Vj (' qn (�5 �.,J V k, inuion Date: 5 ' (0 • (� Job Site Address:Z8 (�✓✓.4 564 c4 L4 City/State/Zip: 4laihr 002671 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 51,500.00 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• a : , . the pains • d pen, ;es it, perjury that the information provided above is . e and coma Sienature:�s'a. IP.a J0 ('U S Sot Is ate: Phone#: SC ) gp t a rip Official use only. Do not write in this area,to be completed mp by city or town offidai 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#: • �2e W0oww, t nwec ? d€WAtedeG , rss rv: 7/7–±t Office Office of Consumer Affairs and Business Regulation 10 Park Plaza- Suite 5170 Boston, Massachusetts 02116 Home Improvement-Contractor Registration 14 �/ Type: Individual RKELLY ,.r 1-- `FY Registration: . 128957 8 RHINE RD P' t Expiration: 06/13/2019 YARMOUTHPORT,MA 02875 Y —, zt� Update Address and return card. Mark reason for change. SCAT 0 20M /11 _�..�..._�n __��.. _ .. `r7 Addrn.. r i riswe..el n F,wnbvment C7 Lnet Card Cirie Pbmrurorraraf/�ollairauae�aectA �_._...__. ._ �..-- �._ Office 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: " tIegitrtration Extitatlon Office of Consumer Affairs and Business Regulation 128957 06/13,2019 10 Park Plaza-Suite 5170 O VER KELLY BosttltTM 02118 sF - r• 110�. , S OUVER M KELLY / \• e �,,, e .. 8RHINE RD. YARMOUTHPORT,MA'02675 Undersecretary Not valid without signature Commonwealth of Massachusetts ®j Division of Professional Licensure Board of Building Regulations and Standards Con structioOSllpei sor Specialty "r CSSL-099167 :` Epires:09/28/2019 $ 1- OLIVER M KELLY 8 RHINE ROAD, , J� T weirs YARMOUTH PORT MA 02676 * ;nw .1 nitrl jO'S • , • • ` Commissioner 1. inCt • • TE A CERTIFICATE OF LIABILITY INSURANCE �A05�ii62o,6Yn 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. , ''g c IMPORTANT: If the certificate holder is an ADDffIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an:endorsement. Xttatement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NONE: Joanna Bednark DOWLING&O'NEIL INSURANCE AGENCY (NC NEO nil: (508)775-1620 FAX Not: ADDRESS: jbednark@dons.com 973 IYANNOUGH RD INSURER(a)AFFORDING COVERAGE MAID• HYANNIS MA 02601 INSURER A: ACE AMERICAN INSURANCE CO 22667 INSURED INSURER B: KELLY ROOFING INC INSURER C: ! INSURER D: ""I' 8RHINE RD INSURERE: YARMOUTHPORT MA 02675 INSURER F: Y COVERAGES CERTIFICATE NUMBER: 270687 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 INSURANCE ADOL SUER POLICY EFF POLICY EXP LIMITS LTRJf1SD wvn POLICY NUMBER (MMNO/YYYYI IMMND/YYYYI COMMERCIALGENERALLWBILIWY EACH OCCURRENCES m CLAIMS-MADE 0 OCCUR DAMAGE TO RENTED PREMISES(Ea oNreoceL $ MED EXP(Any one person) $ DV - _ N/A PERSONAL&AINJURY $ — GEM.AGGREGATE LIMIT APPLES PER GENERAL AGGREGATE _ $ _ POLICY n J7CT 0 LOC PRODUCTS-COMP/OP AGO $ IOTHER: $ ' AUTOMOBILE LIABILITY COMBINED SINGLE LIME ' $ (Ea aoydenp — ANY AUTO BODILY INJURY(Par person) $ ALL OWNED AUTOS N/A BODILY INJURY(Per Bode/mg $ HIRED AUTOS _ AUTOS (Per accItIeN)DAMAGE $ $ UMBRELLA LIAROCCUR EACH OCCURRENCE $ EXCESS LIAB H CLAIMS-MADE N/A AGGREGATE $ DED RETENTION{ �/ $ WORKERS COMPENSATION X STATUTE ER AND EMPLOYERS*LIABILITY YIN ANYPROPRETORIPARTNEPoErCU11VE E.L.EACH ACCIDENT $ 500.000 . A OF EMBEREXCLUDED? wA RA N/A 6S62UB8H08580918 05/10/2018 05/10/2019 • (Mandatory In NH) E.L.DISEASE-EA EMPLOYEES 500,000 4If yyes, IPTION ands DESCRIPTION OF OPERATIONS babas E.L DISEASE-POLICY LIMIT $ 500,000 • N/A DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Ramerk.Schadul.may Da attached II mon apace N raqulrad) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is gigven to pay-„ claims for benefits to employees in states other than Massachusetts if the assured hires,or has hired those employees outsideof Massachusetts.'r This certificate of insurance shows the policy in force on the date that Oda 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-compensationfinvestigationst • CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. Building Dept 534 Winslow Grey Road AUTHgjM REPRESENTATIVE -Th South Yarmouth MA 02664 D iS C,� .. Daniel M.Cro /By,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 • -