BLD-19-003024 Og YAR. 1 Mice Use only
4.O
OiZ t: ! C Pamitlt t, J
•• �'� H 'Amomr V
I
N10. crx Permit expires 180 days from
issue date
EXPRESS BUILDING PERMIT APPLICAT
TOWN OF YARMOUTH NOV 15 2018
Yarmouth Building Department
1146Route 28 BUI)!DIr -1 r)i. ENT
South Yarmouth, MA 02664 By Lel
I (508)398-2231 Ext. 1261
CONSTRUCTION ADDRESS: S GkC-314 CL0Q. A4AAMna
ASSESSOR'S INFORMATION: •
Map: Parcel:
owNER:QA\L Som_ a ,\v,.oS -Q kp„,* ' • `14 o,ri-k M4 026
NAME RESENT S ADDRESSTEL #
CONTRACTOR: iLet .14 Q.Oot t a cT lic,- `d Qui o r, FWD q....40,„„ MA e b lS
NAME MAILING ADDRESS TEL# % SO C1 Lt6�0
E Residential 0 Commercial�t �^► Est Cast of Construction S C�,�q^�00 /
Home Improvement Contractor Lie.# IQ-CS 9 S / Construction Supervisor Lie.# lo 9 I b 7
Workman's Compensation Insurance: (check one) 7
0 I am the homeowner 0 I am the sole proprietor f I have.Worker's Compensation Insurance C �1
Insurance Company Name:•4(',h 415111C4-06 Worker's Comp.Policy 65(27(..11.205�7')0�y Z>5 E o O 1
WORK TO BE PERFORMED
Tent Duration (Fire Retardant Certificate attached?) Wood Stove
Siding: #of Squares Replacement windows:# Replacement doors: #
Roofing: #of Squares 22 ( f)Remove existing*(max.2 layers) Insulation
Old Kings Highway/HistoricDiist. ( )(Reeeplacingg like for like • Pool fencing
'The debris will be disposed of at 'T"- i j S lis.s-c It.
Location of Facility
I declare under penalties of perjury that the statements herein contained are true and correct to the best of my knowledge and belief. I understand that any false answer(s)
will be just cause for da'.. , ation of my license and fo cutioa under MG.L Ch.268,Section 1. f
sio
Applicant's Sip.. • s _ . 0 L Date: If ( 1 J ( l f5
Owners Siena r
// Date:
Approved By: / 2 -ESDate: /Aisig
Buildin9 .ffi or d- gree) E DRS:
oir
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
b!L Department ofIndustrial Accidents
•
ese= 1 Congress Street, Suite 100
'IN "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 Legibly
Name (Business/Organization/Individual): IkEl l -CaUvcs- cmc_,
Address: 9) \Y kJe
City/State/Zip: ‘kRC MO,.'M MA o-1c Phone#: 50% Sci' O
Are you an employer?Check the appropriate box: Type of project(required):
1.0 f am a employer with t employees(MI and/or part-time)." 7. Q New construction
{ 2.0 I am a sole proprietor or partnership and have no employees worldng for me in 8. 0 Remodeling
any capacity.[No workers'comp.insurance required.]
3. I am a homeowner doingall work r 9. 0 Demolition
myself[No workers'comp.insurance required.]
4.0 I am a homeowner and will be hiring contractors to conduct all work on my property.ro I will 10 Q Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11.Q Electrical repairs or additions
proprietors with no employees.
12.0 Plumbing repairs or additions
5.0tarn 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.EriOOf repairs
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.0 Other
152,§1(4),and we have no employees.[No workers'comp.insurance required]
*Any applicant that checks box 41 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 subcontractors 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:t ('fJ ,F Pa(4
Policy#or Self-ins.Lic.m:(35 b 2- ti i,% etZ-)fO 1C/ Expiration Date: 6 l� q
Job Site Address: p C 13t City/State/Zip:go, ` r)tJ o9bel
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration d.te). I
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 hereby cerci dl the pains and pena ' perjury that the information provided above is true and correct
Sienature: L Date: , 1.6 lqs
Phone;#: 5OCS SO 4by°
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#:
KELLY ROOFING MA CSL #99167 PH 508 509 4640
8 RHINE ROAD. MA HIC #128957
YARMOUTHPORT
MA 02675 kellyroofing@icloud.com
August 24' 2016
Proposal submitted to Gail Stone of 31 Augusta Way, South Yarmouth MA
We propose to supply all materials and labor necessary to remove and replace the
existing asphalt roof at the address above.
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 the first three feet of
eaves in all valley areas and around all protrusions.
Remainder of deck to be covered with #15 Felt Paper.
Lifetime limited warranty Architect style shingle to be installed, (Color To Be Specified)
All shingles to be storm nailed. (6)
Bathroom vent pipe boots to be replaced with new.
Install Shingle Vent II Ridge Vent On All Ridges with Hand Nailed Caps.
Repair/Replace all flashings as necessary.
Protect all walls, windows, decks, plants, shrubs, etc. during roof strip.
Complete cleanup of area during and after procedure including all nails and cleaning of
gutters.
Obtaining of Town Permit.
At a Total Cost of$6900
Payment schedule,50%at Project Start, balance upon completion.
Respectfully Submitted, Oliver Kelly.
Proposal accepted by; Date / off- 120/
•
I% --r�
c 12e o/nwizanwea o/G-Alcz(macAuoeG' ,
i Office of Consumer Affairs and Business Regulation
�`„"' 10 Park Plaza- Suite 5170
Boston, Massachusetts 02116
Home Improvement-Contractor Registration
C
F-77:7-:"-__:,t---------7=2--ti
(^� ^ s ,' _ Type Individual
Ci r �-r„ I __v Registration: 128957
8 RHINE RDLLY I i ! —a r Expiration: 06/13/2019
YARMOUTHPORT MA 02675 inf `� `
\' z7� 7
t„� (r .” yir" F
y,,"� Update Address and return card. Mark reason for change.
SCA 1 0 20M-05111
_- " _��..]_-A_rAMae ri cony d r-i F�T_nlgvment 0 Lngt Card,—
Cg2eonsAoflwea//nfo&saAene/h
Office of Consumer Affairs a Business Regulation
>laZaTIP
„ HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only
114- It r� TYPE:Individual - before the expiration date. if found return to:
n4E gealstratlon Expiration Office of Consumer Affairs and Business Regulation
126957 06/13/2019 10 Park Plaza•Suite 5170
R KELLY I
)_ BostOlcht 02118
F { sem.
OUVER M.KELLY C �, ..,
8 RHINE RD.
YARMOUTHPORT,MA 02675
64-cc-illy-
Not valid without signature
Commonwealth of Massachusetts
”;-f Division of Professional Licensure
• Board of Building Regulations and Standards
ConstructioA:Sl1 cvisorSpecialty
CSSL-099167 1 Ejyires: 09/28/2019
•
• OLNER M KELLY f f C
6 RHINE ROAD,,
• YARMOUTH PORT MA 02676 *.` f 1
._t-orcicooltS- _ -
•
Commissioner V'"" 4.-- 1„'^ cI
®
A`QRDCERTIFICATE OF LIABILITY INSURANCE DATE(MWDD
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 CONTACT
NAME; Linda Sullivan
PHO
DOWLING&O'NEIL INSURANCE AGENCY box N Eon (508)775-1620 FAX,No,:AD"IE :DRss;
Isullivan@doins.com
9731YANNOUGH RD INSURER(S)AFFORDING COVERAGE NAIL.
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:
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 SUBS POLICY EFF POLICY EXP UMIT9
LTR !NW wen POLICY NUMBER IMMVDD/YYYY1 IMINDDA'YYVI
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $
DAMAGE TO RENTLD
CLAIMS-MADE nOCCUR PREMISES(Es occur,enel $ _
— MED EXP(Any one person) $ _
_ N/A PERSONAL&ADV INJURY $
GEN%AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $
POLICY❑PRO-T n LOC PRODUCTS-COMP/OP AGG $
JEC
OTHER: $
AUTOMOBILE UABILITY COMBINED SINGLE LIMIT $
(Ea ecademl _
ANY AUTO BODILY INJURY(Per person) $
ALL OS AUTOS SCHEDULED
AUTOS N/A BODILY INJURY(Per accident) $
_
NON-OWNED PROPERTY $HIRED AUTOS AUO (Per accident)
$
UMBRELLA UAB _ OCCUR EACH OCCURRENCE $ _
EXCESS UAB CLAIMS-MADE N/A AGGREGATE $
DED RETENTIONS S
WORKERS COMPENSATION ts/ PER OTH-
AND EMPLOYERS'LIABILITY Y/N STATUTE ER
ANYPROPRIETOR/PARTNERIEXECUTIVE E.L.EACH ACCIDENT $ 500,000
A OFFICEFUMEMBEREXCLUDED? WA WA WA 6362UB8H08580918 05/10/2018 05/10/2019
(Mandatory In NH) E.L.DISEASE-EA EMPLOYEES 500,000
II yes desaibe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000
N/A
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached B more apace Is reendmd)
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/workers-compensatlonhinvestigations/.
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 02833
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