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Home My WebLink AboutBLD-19-003381 /.Ot„YgR,t 1.Otte Use Only w T t� . �, piss‘ Permrtlf H �• �l . 4' 'Amount D cam` 'Permit expires 180 days from issue date Et-Iq-CW38-/ CE O V U • EXPRESS BUILDING PERMIT APPLICAT O TOWN OF YARMOUTH DEC 04 2018 Yarmouth Building Department 1146 Route 28 BUIL !' :' A "1' South Yarmouth, MA 02664 By -- _.-1____ (508)398-2231 Ext. 1261 CONSTRUCTION ADDRESS: /gq Slc,V( (, k W� Yeoai ASSESSOR'S INFORMATION: Map: (� Parcel: OWNER:& 6 kAC%I.D ll_At . 1Z 1 Q CJ:t11at ac IJ\, i..,440..„.„, NAME PRESENT ADDRESS - TEL. # CONTRACTOR: 106u4 Y.CO%tv3CTr Its - g 1�Ulaug Q AJC 4MMOafru, :MA EQ.b`IS NAME MAILING ADDRESS TEL# H Residential 0 Commercial Est.Cost of Construction S.56,0,1 Home Improvement Contractor Lic.# 19ES 9 S7 Construction Supervisor Lic.# v'9 I b 7 Workman's Compensation Insurance: (check one) 7 0 I am the homeowner 0 I am the sole proprietor ® I have Worker's Compensation Insurance/ �y C ry Insurance Company Name:4r,N 4M.,erIc Worker's Comp.Policy'642DA'bgOs5g0g1 WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares A ( 7)Remove existing*(mai.2 layers) Insulation Old Kings Highway/Historict Dist. ( )./Replacinglike for like Pool fencing • *The debris will be disposed of at 1 u7+y n" .1 i S S-C—e-Z 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 d,•::. -. •, ation of my license and feat ution under M.G.L Ch.268,Section I. �J Applicant's Sign" .• , —cab __ 0 IlkDate: '7 1k ( �D Owners Signature(or attachment) , Date: t ,` c Approved By: ✓ �4.� gh�/` Date: I I�— 13 — I O Building Official(or desi e) EMAIL ADDRESS: Zoning District: _ Historical District 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District Within 100 It of Wetlands: 0 Yes 0 No 0 Yes 0 No =i'\ The Commonwealth ofMassacltusetts _ -a= Department oflndustrialAccidents =Firm1 Congress Street, Suite 100 a = Boston, MA 02114-2017 ,�tao www.tnass.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): r+`€l l yt 2 u1'acr Address: 9, • City/State/Zip: \km...KG"1lk MA Orbic Phone #: 50% ,S -fit 46 ) Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with 1 employees(full and/or part-time).* 7. 0 New construction 2.01 am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling • any capacity.[No workers'comp.insurance required.] 3. I am a homeowner doing all work myself 9. ❑Demolition g ys No workers'comp.insurance required]t 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.❑I am a general contactor and I have hired the sub-contractors listed on the attached sheet These sub-contractors have employees and have workers'comp.insurance? 13.1y5.00f repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.E 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 sub-contractors and state whether or not those entities have employees. If the sub-contractors 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 /1 Insurance Company Name: r,F Policy p or Self-ins}}.Lic.m:(351) 2.V i, % QJ5Q,O,\< Expiration Date: l Job Site Address: 'S( <rtl t,(L (I�;4 t}C1 City/State/Zip: A-Q-A.L.e 26- 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 hereby certi d r the pains and pen perjury that the information provided above is true and correct Signature: Date: 1) Phone#: So'S So ck 4(ate \ \ 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 k: KELLY ROOFING PH. 508 509 4640 8 Rhine Road MA C.S.L.#099167 Yarmouthport MA H.I.C.R.#128957 MA 02675 May 22'2018 Proposal submitted to Janice VanDerAa of 189 Silver Leaf West Yarmouth MA. We propose to supply all materials and labor required to remove and replace the existing double layered asphalt roof at the address above. Protect all walls,Windows,shrubs,plants etc.during roof strip. 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 first Six feet of all eaves, in all valley areas and around all protrusions. Remainder of roof deck to be covered with synthetic underlayment. Install limited lifetime warranty Architect style Shingles,color to be specified, All shingles to be storm nailed(6) Replace plumbing vent pipe boots with new. Repair/Replace all flashings as necessary. Install Shingle Vent II ridge vent with hand nailed caps. Complete Clean up off all areas including all gutters and all nails atter project complete At a total cost of$5600 Payment Schedule;Balance upon Completion Proposal Submitted by:Oliver Kelly Proposal accepted by:(�u„,: .•/ Date/f//7/2018 This proposal is valid for 45 days from date above,please call to verify thereafter. A�® CERTIFICATE OF LIABILITY INSURANCE DATE(MWD tis 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. It 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 AX DOWLING&O'NEIL INSURANCE AGENCY PHONEmtt E,N (508)7751620 INC.ENo); ADDRESS: Isullivantdoins.com 973 IYANNOUGH RD INSURER(S)AFFORDING COVERAGE NAICF HYANNIS MA 02601 INSURER A: ACE AMERICAN INSURANCE CO 22687 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 SUER POUCY EFF POLICY EXP LIMITS LTR - Min wve POLICY NUMBER (MMNdYYYYI IMWDDMYYYYI COMMERCIAL GENERAL LIABILITYEACH OCCURRENCE $ • CLAIMS-MADE El OCCUR PREMISES IEe o�ccurrrence) $ _ MED EXP(Airy one person) $ — N/A • PERSONAL a ADV INJURY $ / GENT.AGGREGATE LIMITAPPL�IEIS PER: _ GENERAL AGGREGATE $ POLICY❑Tei I I LOC • PRODUCTS-COMP/OP AGG $ OTHER' $ • AUTOMOBILEUABILITY COMBINED SING E)—LIA $ _ IEe accident) _ — ANY AUTO BODILY INJURY(Per person) $ AOWNED SCHEDULED OS N/A BODILY INJURY(Per accident) $ AUTOS NOTNOVJNED PROPERTY DAMAGE $ HIRED AUTOS _ AUTOS (Per accident) $ UMBRELLAUAB OCCUR EACH OCCURRENCE $ - EXCESS UAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ �/ $ WORKERS COMPENSATION X]PTATUrE ER AND EMPLOYERS'LIABILITY - A OFFICEORJMEMB XCLUDEDixECUTIVE YI�T WA WA 6562UB8H08580918 05/10/2018 05/10/2019 E.L.EACH ACCIDENT $ 500,000 (Mandatory In NH) I I _ E.L.DISEASE-EA EMPLOYEE $ 500,000 V yea desats abler DESCRIPTION OF OPERATIONS below EL.DISEASE-POLICY LIMIT $ 500,000 • N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached II 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/worker.compensationRnvestigations/. • CERTIFICATE HOLDER CANCELLATION e 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 DChatham MA 02833 I O n lel 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 Commonwealth of Massachusetts • VII of Professional Licensure Board of Building Regulations and Standards ConstructioASUP4Msor Specialty CSSL-099167 -..-7 1, Expires:0912812019 OLNER M KELLY 74 i - . - 8 RHINE ROAD, ', r YARMOUTH PORT MA 02675 ♦ r r� , ,. A rv' c{ ' rr Commissioner cciL polnmo4tevea 1 a ackmet6 -� Office of Consumer Affairs and Business Regulation 2,-e.,,, 10 Park Plaza- Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Type: Individual i,; r Registration: 128957 OLIVER KELLY ,";' I i ; . E>piration: 06/13/2019 8 RHINE RD YARMOUTHPORT,MA 02675 12,„, 7- h Ic "` _— Update Address and return card. Mark reason for change. SCA 1 O 20M-05/11 _ _ fl AdAro•• T'1 mnr..K,l n Franinum.nt r_7 tact Card -_- --"-'---- le oioner weer/1A eloilasineA"JelT ---"-. - ._— . Mee of Consumer Attain&Business Regulation Registration valid for Individual use only �. — _if HOME IMPROVEMENT CONTRACTOR before the expiration date. B found return to: 4 ',' TYPE:Individual Y peoistratiort ) xolratlon Office of Consumer Affairs and Business Regulation 9 _ 128957_ 06/13/2019 10 Park Plaza-Sults 5170. ,s-^•; �',� Boston;MA 02115 ,..-- �' O1�IVER KELLY ) „,.,-----/ ,. f ; 8RHIN RM.KELLY 61 a B RHINE RD. - -• Not valid without signature u YARMOUTHPORT,MA 02675 Undersecretary'•-.._