Loading...
HomeMy WebLinkAboutBLD-19-002791 Office Use Only -• 1 .Ot• 4k. • - , S2 C C Permit* ; 0 1 �' Amount Sb '- ' c• MTT , *'"`e, fi. {�.J (� n /yam�•� !Permit expires 180 days from !. c..: :.. etb- q—Cli gI .issue date ( RECEIVED EXPRESS BUILDING PERMIT APPLICATIO TOWN OF YARMOUTH NOV 0 6 2018 Yarmouth Building Department 1146 Route 28 BU 'E�' T South Yarmouth, MA 02664 aY — — — ,U.S508) 398-2231`Ext. 1261 • CONSTRUCTION ADDRESS: I� 25\ Qa-� " 6. 41;42-Mar ASSESSOR'S INFORMATION: , . , � Map: `pParcel: 20OWNER: Af cl-ncv�QA ! 1 �Q,lb a WGS'1 0AaOJH( (Jaws , /ME ^^ �PRESENTA(D�DRES '�a TEL # CONTRACTOR: LLF.t Lk POOLut��G IS fCjJ ik On �'�u 1111 021,1Sc^ �- N £$"- ING ADORES TEL.# Sca 509 t(6c( ,H Residential 0 Commercial Est Cost of Construction$ 101000 Home Improvement Contractor Lic.# ige I si Construction Supervisor Lic.# net (/ 7 Workman's Compensation Insurance: (check one) / ❑ I am the homeown 0 I 1am the sole proprietor / I have Worker's Compensation Insurance 11,,r+/ u Insurance Company Name: ('£ t ,D. ..M3 Worker's Comp.Policy#Y•:��&8 FSS 3 0 q t$ WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares 30 ( )Remove existing*(max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing V *The debris will be disposed of at �As1t©%)t'& �ith 'eke-- Location of Facility I declare under penalties , • ju at the statements herein i'ned are fru ift i rrect to the best of my knowledge and belief I understand that any false answer(s) will be just cause fo •enial• of my license an. r.r pro c r L Ch.268,Section 1. Applicant's Si:'atur•' IF I / - St. ' Date: `' I O Owners Signature(or attachment), - - air . - Date: D Approved By: d• f _. Date: //-7 -/8 Bui Vivi vi(o designee) ya• L 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: 0 Yes 0 No 0 Yes 0 No The Commonwealth of Massachusetts t —"—= 1_*!/ Department oflndustrialAccidents i _ w 1 Congress Street,Suite 100 _ Boston, MA 02114-2017 ', ����' www mass.gov/dia - Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Le_eibly Name (Business/Organization/Individual): Address: • ! City/State/Zip: Phone#: Are you an employer?Check the appropriate box: y • --_ . Type of project(required): 1.0 I am a employer with employees(full and/or part-time).* 7. 0 New Construction 2.0 1 am a sole proprietor or partnership and have no employees working for me in g. 0 Remodeling any capacity.[No workers'comp.insurance required.] -- -. 9. ❑Demolition 3.0 I am a homeowner doing all work myself[No workers'comp.insuance required.]t, ,_ : 10 0 Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that an contractors either have workers'compensation insurance or are sole 11.❑Electrical repaiis'or additions proprietors with no employees. - - 12.❑Plumbing repairs or additions 5.1:11 am a general contractor and I have hired the sub-contractors listed on the attached sheet These sub-contractors have employees and have workers'comp.insurance.: 13.❑Roof repairs We are a corporation and itsofficers have exercised their right 14.0 Other 6.0 rpoofexemptionperMGLc. _ 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box 11 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. If the subcontractors 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 and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: • City/State/Zip: 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=lit 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 hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signature: - -•-• Date: L- Phone#: Official use only. Do not write In this area,to be completed by city or town official City or Town: Pennit/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#: _ . ,.._. . , . . , . ,,,. . . , . .. , , .. . .. . . .. _ . . . . ... . . . . . . . .. _. • " • - ' • • • . - ''• ' • . '-' ' . . ' .• . ' ' . '.... ' . , .... , ,-.. • _ el it ... . 0 inalii .i, ;.: 11. .164 Jill: i ii . it.i .1''..'''''.'4: . . . ., • ,.... ,.17:::I K lt • 2 1 rvi ,,,,. t ri - 1 1)EA R ' . i , - i'r11171 ICI' pi . r , ,,,,, . I , : _ •, ,. . , ., .,.., ( (to ii i e, aiii,, ::5 . 1 ,st i . 3 j • .4. 1. 01 is 1 t4 ..1 ' n .:1, n 1 I ], ' ',-,".',':-.t:, .• . 8110 ' • . ., . . (.4, lb is 11 cp 7,:. frIt , 7 I I'14 tja ' ' . Cn. 1 . ... r II 0 i IiI, i 1 ,,,. 0‘.;,4, 11 IP . 14 , , : ...: 41.1 8. ' Ili 10 tr. t-f° I ' , 4 . ... .. . . L. ,, r. itil a (A It . • . ..- 4 •- • id • u • t•-• F. ‘.../, f ' (el; --k:. 2 - . i - .. . - ) • - : ' 4 I --0 r 1 is 1' I '''' . .' . 1 illti. il 11 ',.. ... .. . ' . .: :•......-.:,,.., . . •.. .. -'..• wi, :.,..., ! i th 17... i . / c.0 t4-isTh: il . .. .... . . r I • I ' ...• . . I ... 1 —7.i iv I I- • . 1 . . . pi. . .. . - ., . V. •:ici.:' • i. m _ . w 0; [ a , ,4 ., . .1 .". . . . p. . 0 los . . • lip ...... .....: . . 1 illi 'll, t111'fillE114'.11: ``'‘-'u) . - • ,--111'1,,slid • • • ' .. -.. . • . 1 sg • 1 . ' i gi • ,., , . . •-, . . it r . .... I . R fip 1 ' r • I i i li 11 . C:Ce-H. ...'1 1 "sii,li; . 19 ifiltr gl l': ,.I: ' I, ill. ..' 1'.1.• •••••' . k ::•irtiNot/t. '1.1s: • , • . . ' ri I • 1, 0,11.11 /./Ipi . -. ..: . 1 , kr . . .ki. ' 4 4 te• • : - - I 1111 • • V ,t8 / . 1[11 ' - 't ' ''. ;' . • PO , • ,. %,-.. N'• t • . • 7( r; 44 1 ' i,.27 t It rk 41 " ' '' , M ki,EY (.1;147, .1 t. "...' .1 ''..:. ( .. ''...,. . . • ' I 1 '' ' - . ... - -- •I ' • . •••• ''' - . - • 1 F P r 14 Et . •• . 4 . r' . ' - ' - • I ; • 4 , ,, , . i... 1 I • • a. ,, p p Eir-] . a. ' 0. . • • 7 tri : P I 1 . .0 t• ..: 511 Ci tjf • .. . . . : 4 mt. .1-) . .- • . f4, R 1 '• 1 li .. I: . i II • • ill • . i • itit.i. a 6 'il ii: roE• • Pi • . . T.. . I ..c. •11. . . • 0 • . , , flit • f‘ . 1 . 1 . R 4 , . , . :' . ' na risil. k. A ; 1 1 . . „. . • , • . . N6 • . 1 . , . • • • . al . • . ' . . A ® CERTIFICATE OF LIABILITY INSURANCE DATE(MWD 'YYY) 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: 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 CONTANAME:CT Linda Sullivan DOWLING&O'NEILINSURANCE AGENCY PHONE (*XS (508)7751620 FAX .No1: ADDRESS; Isullivan@doins.com 973 IYANNOUGH RD INSURER(S)AFFORDING COVERAGE NAIL* HYANNIS MA 02601 INSURER A: ACE AMERICAN INSURANCE CO 22667 INSURED INSURER B: KELLY ROOFING INC INSURERC: • 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 WTH 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. ILSRADDLTYPE OF INSURANCE _ W WYD POLICY NUMBER IMBR �WDDCDNYF F POLICY EXP LTR YYI (MM/DD/YYYY, OMITS COMMERCIAL GENERALWBILRY EACH OCCURRENCE S DAMAGETO RENTED CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ MED EX?(My one person) S _ N/A PERSONAL&ADV INJURY $ GENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE I n POLICY PROT- n LOC PRODUCTS-COMP/OP AGO $ JEC OTHER: S AUTOMOBILE � COMBINED SINGLE LIMIT $ _ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ — ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per accident) $ NON-OWNED (Per accaEI nDAMAGE $ HIRED AUTOS AUTOS S UMBRELLA!JAB _ OCCUR EACH OCCURRENCE S EXCESS UAB CLAIMS-MADE N/A AGGREGATE S DED RETENTIONS �/ $ WORKERS COMPENSATION STATUTE ER AND EMPLOYERS'LIABILITY AN/PROPRIETOR/PARTNER/EXECUTIVE T/N E.L.EACH ACCIDENT S 500,000 A OFFICER/MEMBEREXCLUDED? WA WA WA 6S62UB8H08580918 05/10/2018 05/10/2019 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEES 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached B more apace 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.govJIwd/workers-compensation/investigations/. 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 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 • , �C—Tc- ��e Wpoini�2owevecoth o/C�!' oac/zeriell mzfr Office of Consumer Affairs and Business Regulation 10 Park Plaza- Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Type: Individual • OWER KELLY -i.=Ci. Registration: 128957 8 RHINE RD 7 yf` Expiration: 06/13/2019 YARMOUTHPORT,MA 02675 ; 1 \ -d 4 * x;11 o f;,1 • Update Address and return card. Mark reason for change. scA 1 0 20M-0W„ ---...—.------.---._—___. /--..,— --_—. n Addr?s• r'1 0-,p.-ii nFmnloymant nLnst Card (792eCec//N//v///pelt//I otaier.iiaditie//i Office of Consumer Affairs&Business Regulation a ( HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYPE:Individual before the expiration date. H found return to: Registration Expiration Office of Consumer Affairs and Business Regulation �'ra''��r 126957 06/13/2019 10 Park Plaza•Suite 5170• s� OLJVER KELLY Boston,MA 02116 «---,;/ • n tr—D •...... ) .--<'` 'r..+r, I..; 8 RHINE RD. YARMOUTHPORT,MA 02675 Undersecretary,. Not valid without signature tar ,.- d • Commonwealth of Massachusetts ' ta Division of Professional Licensure Board of Building Regulations and Standards ... Construction-SLpdrVisor Specialty CSE L-099167 .. 7- Eau • • OLIVER M KELLY •" I 2 ' 8 RHINE ROAD, YARMOUTH PORT MA 02676 .. Commissioner "" Ve