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Home My WebLink AboutBLD-19-3020 Og,Y Office Use Only it **4 �" ! C, ;Pennit! 0 - ?' . 'Amount 5O ` M1T l- `�.,....n• cca Permit expires 180 days from • BLS/-'I I-0030,2 f,03Da D issue date ED EXPRESS BUILDING PERMIT APPLI V 0 E ! 1I TOWN OF YARMOUTH NOV 15 2018 Yarmouth Building Department 1146 Route 28 BUIL F R NT South Yarmouth,MA 02664 nv — —� (508)398-2231[[[ Ext. 1261 CONSTRUCTION ADDRESS: 3�c Z 44-1-$4) Si �0 -742.4/0z) � ASSESSOR'S INFORMATION: {Lib Map: � � - Parc�el: Z OWNER:� aA+'rJ (n�O.-- 33 i�tc (\� IA IAA rnA.P9LC 1-1kA, 0'm15- NAME 1//�,�^/� tic) ADDRESS TEL. II w' / CONTRACTOR: Il�t- NAME j YCS-L .1f. - I�MAl1,fNG ADC Wt (Lp4D 1 t1TE ,10,5 P8'LT O42(O 75 17l sidential 0 CommercialQ, Est.Cost of Construction$700n Home Improvement Contractor Lie.# IZS? , Construction Supervisor Lie.# '+1yq q 1• n b '/ Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor ❑ have Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy# WORK TO BE PERFORMED • Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares 2 y ( ✓)Remove existing*(max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: -!� 7 VI/ Location of Facility I declare under penalties of perjury that the statements herein co4 are true and correct to the best of my knowledge and belief. I understand that any false answer(s) will be just cause for de ' .agion of my license: tion under M.G.L Ch.268,Section 1. Applicant's Signator : ' 0 — I � /8 �7 Dale: //• if • Owners Signature(or attachment) . Van .....— , Date: //. 1/- /O Approved By: / /-o/ / Date: /77-57,g dinye t trial or designee) r • L ADDRESS: - / Zoning District: Historical District: 0 Yes ❑ No Flood Plain Zone: 0 Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No j M1 .‘. Fitiknit: El ' �H us l H El, L ' ��ryNjM p F ❑ 1:1 ' �'' u' �' 1F FI S ' 14 / ..Pr„,„ IF 'iii 01 P �,, 1?frithrliirme . ry 1 : ci. oil 4 D a � ii 1 1 z 114!+ M.; cii 'ID , 111611 � hi ' ., N 'C .rI 1Y'� 141 .. 0 II' ` LI. , 1 NMI• .I' 11 lit, 6' 11 .M. 1.f{�Q;{� rl E' F I MPP 4—li • 4 , I 1 f, - .. M m . F 8. • • ' • * ..T wkl . ' 9It. I. m 1. r. a, . 1 / I• Il is } �' ill q fll j . 111 ,1 kr g c-jiti 1 ,-) blEEp fli I I I slit '? I li 1 I . ,.. t„, , p 8orpa :4 PI fri 0\ p 4 4 iiili.. .frii$' '" I I • . ' . . "-ICS ! 1 in gi i eiti c'.. 1 .11 I'll; lj / ril 4) • •: • III i I ® , iF. cp N . --II-) 1. 1 1 I IFS • . I: • a, t . G,3 . • •• TE D CERTIFICATE OF LIABILITY INSURANCE DA 9(MWDDa 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 POUCIES 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 DOWLING &O'NEIL INSURANCE AGENCY PHONE (NC. d E.D. (508)775-1620 LAIC.NM E-MAIL ADDRESS: lsullivan@doins.com 973 IYANNOUGH RD INSURER(S)AFFORDING COVERAGE NAILS 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. NOTLMTHSTANDING 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 SUBA POLICY EFF POLICY EXP LIMITS LTRIVSD WVD POLICY NUMBER IMM/DOMYYY) IMWDD/YYYYI COMMERCIAL GENERAL LIABILRY EACH OCCURRENCE $- DAMAGETO RENTED CLAIMS-MADE ❑OCCUR PREMISES(Ea occurrence) $ MED EXP(My one person) $ N/A PERSONAL SADV INJURY $ GE 'L AGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE °ECT $ POLICY f TIO- E LOC PRODUCTS•COMP/OP AUG $ J OTHER- AU OMOBILE THER:AUTOMOBILE LIABILRY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person)— S ALL OWNED SCHEDULED AUTOS N/A BODILY INJURY(Per accident) $ AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS _ AUTOS (Per accident) $ UMBRELLA UM _ OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION OTH- AND EMPLOYERS'LIABILITY ^ STATUTE ER ANYPROPRIETOR/PARTNER,EXECUTIVE Y/N E.L.EACH ACCIDENT S 500,000 A RNEMBEEXCLUDED? WA WA WA 6S62UB8H08580918 05/10/2018 05/10/2019 (mandatory In NH)) E.L.DISEASE-EA EMPLOYEE $ 500,000 K yes describe under DESCRIPTION OF OPERATIONS below E DISEASE-POLICY LIMIT S 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached Y more space 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.govllwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POUCIES 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 _ MA02633 Daniel M.Cr iy,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 • e2e Worl'JvmonwecS o/a/ffai aclue-ed/o n Office of Consumer Affairs and Business Regulation �;;, 10 Park Plaza- Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Type: Individual * tratiom 128957 OLIVER KELLY R�iration: 06/13/2019 8 RHINE RD YARMOUTHPORT,MA 02675 Update Address and return card. Mark reason for change. SCA1 O 2061-0511 n Andreae r-10en pWai fl c,..gln..mnptLnstcard_ 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: G � pegistration gxoiratiort Office of Consumer Affairs and Business Regulation 128957 06/13/2019 10 Park Plaza•Suite 5170 R KELLY - • Boston;MA 02116 OLIVER M.KELLY 8 RHINE RD. U V Not valid without signature YARMOUTHPORT,MA 02675 Undersecretary 8 Commonwealth of Massachusetts ®: Division of Professional Licensure Board of Building Regulations and Standards Construction-Supervisor Specialty CSSL-099167 EApires:09/28/2019 OLIVER M KELLY -= 8RHINE ROAD f , YARMOUTH PORT MA 02676 iso; Commissioner CL .. -