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HomeMy WebLinkAboutBLD-19-4137 �.Og: _.R :Office Use Only rt'. r; ! �p •Permit# o .4 c SO1 Amount Q'fia "-� `�$ • 'Permit expires 180 days from issue date Bib—l c/—(11-113'7 RECEIVED • EXPRESS BUILDING PERMIT APPLICA • TOWN OF YARMOUTH JAN 15 2419 Yarmouth Building Department 1146 Route 28 But . 2.261/431,1 T South Yarmouth,MA 02664 aY: ' CONSTRUCTION ADDRESS: (508)398-2231 Ext. 1261 CONSTRUCTION �lS g--4-12c-to tit . kts,....),.., ASSESSOR'S INFORMATION: Map: t, Parcel: OWNER:94\41%01\Z <�ks (4 Q-Nx3�a l,{ MP\ Mel NAME PRESENT 4E-UM __GTEL # CONTRACTOR: w4 Q�r-traCT Iii:..- Qui Ci QA grAu,O>.,n4 MA QQ).b7S NAME MAILING ADDRESS TEL d 5% <09 N 640 H Residential ❑Commercial Est Cost of Construction S 5-000 •Q Home Improvement Contractor Lie.# I.Q S l 7i-7 Construction Supervisor Tic.# oe q l b.7 • Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor 71.-have have Worker's Compensation Insurance Insurance Company Name: (E. 4N c(!I G4:4 Worker's Comp.Polity'6.56.7, QCC5 q_ 2 ,g t) ? I eir WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares t}�� ( f)Remove existing*(max.2 layers) Insulation Old Kings Highway/Histto^�ri^�c.�Diist.� ( )Replacing like for like Pool fencing rlite debris will be disposed of at g4Q4M,G+.+ � '1f 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 denialeocation of my license and . ' . - ution under MGL Ch.268,Section 1. 1 / C Applicant's Sign:. s., .AS .fit_L Date: ( l S 1 Owners Signa ire attachIrr.r„rf t �� /�i Date: / 6 'I Approved By: /�1i� � Date. /t/IT/7 Building•i. . EMAIL ADDRESS: Zoning District Historical District 0 Yes ❑ No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District Within 100 R of Wetlands: • 0 Yes 0 No 0 Yes 0 No ko • • • f ; cilti .i. It il .74 -1..A fill . ii .. • 1 -.. 1 ',acsv• :3 111 ' ' • ' l• all - . . .•,9, .-1, ❑ 0000 ❑ ❑ NI .el b d.� I • , its, t I . .i. .1 441 T1it" ' . . ..,. . .. . . • l9 �o 1 , 1 k° 1 'Ea 1 1 .Nil slit 11 • ' . •taf: • la ! 4 • 6 td w c ❑1-4 'CI i'' al e t 1 kV 1`- { ,1ItlF�1�71I , � 1 { a til 1 I 1 is 4 1 _ . ::.'WWW , ... Y ... i ' J s I .,,... ..... . ,,,,/ • ,,,'�yj1 ,..C WWW �{1_., Y .:, ' i li -_, . . qiita. 1 C+Yi" C 11w [� 1 Y[I 1 Qq1 pXXq;,, , 1 1:10 , 11:(111' 11n1 4./ `�t1t J1i! 1} ;1jh' Irop � ?IdH I�ff„� ',11 ii ? � :P1',th' I1UV +a;t? g li ;IrlJhr �.. K ' �� h� d t14 .1 at { W • A^ ® DATE(MWDDYYYY) a-- CERTIFICATE OF LIABILITY INSURANCE 1.....------ 10/24/2016 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). PRODUCERT i CUMEACT Linda Sullivan DOWLING&O'NEIL INSURANCE AGENCY °�"N pito: (508)7751620 (A/C.No): E-MAIL DDRI E • SS: Isulllvan@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 INSURER C: INSURER D: 8 RHINE RD INSURER E: YARMOUTH PORT MA 02675 'INSURER F: COVERAGES CERTIFICATE NUMBER: 329171 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 POUCY EXP LIMITSI LTRsun WVD POLICY NUMBER IMWDD/YYY19 (MWDD/YYYY) COMMERCIAL GENERAL UABIUTY EACH OCCURRENCE S DAMAGE TO RENTED CLAIMS-MADE ❑OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) S — _ N/A - PERSONAL a ADV INJURY S — GENE AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S POLICY nref Ej LOC PRODUCTS-COMP/OP AGO $ — OTHER' $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident _ ANY AUTOBODILY INJURY(Per person) S AOWNED SCHEDULED AUTOS N/A BODILY INJURY(Per accident) S - AUTOS NON-OWNED PROPERTY DAMAGE —$ HIRED AUTOS _ AUTOS (Per accident) S UMBRELLA UAB _ OCCUR EACH OCCURRENCE S EXCESS UAB CLAIMS-MADE N/A AGGREGATE S DED RETENTIONS X $ WORKERS COMPENSATION STATUTE ETH- AND EMPLOYERS'LIABILITY A OFFICER/MEMBEROEXCLUDED??ECUTIVE WA WA WA 6S62UB8H08580918 05/10/2018 05/10/2019 E.L.EACH ACCIDENT S 500,000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE S 500,000 lI yeaCRIPTION des¢ibe CIF 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 If 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.govfiwd/workers-compensationfinvestigationst CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Silvestri Building Group LLC ACCORDANCE WITH THE POLICY PROVISIONS. 122 Seventh Avenue AUTHORIZED REPRESENTATIVE Hyannis i MA 02601 Daniel .Crp vIeey,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 2//e Volninoluveca, a/cArmac eez Office of Consumer Affairs and Business Regulation 10 Park Plaza- Suite 5170 Boston, Massachusetts 02116 . Home Improvement Contractor Registration Type Individual 1; i-, Registration: 128957 OLIVER KELLY I Expiration: 0W13/2019 8 RHINE RD YARMOUTHPORT,MA 02675l.": ,-_, ":"..-:`, r 1 f • Update Address and return card. Mark reason for change. SCA 1 0 20M-OS/11 _.__ __.__�l�Ae_. . n AAdleaa f1 O.npwgl Ft Peeglpvmapt r]Lne}Card ___. 6rmn,n/twee//Ao/cv(fitAnrAteieffi e • G� Office of Consumer Affairs A Business Regulation 11M HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:IndMdual before the expiration date. If found return to: �a pealrnation Fxoirotlon Office of Consumer Affairs and Business Regulation 128957 06/13/2019 10 Park Plaza-Suite 5170 "--\ VER KELLY Boston;MA 02116 _„.-»�,.� , �a_ t 4j OUVER M.KELLY \�..CcQ.f-- _ �-� �y _` B RHINE RD. L,] 4 YARMOUTHPORT,MA 02675 Undersecretary--._ Not valid without signature i, u Commonwealth of Massachusetts Ili Division of Professional Licensure Board of Building Regulations and Standards Construction Supervisor Specialty CSSL-099167 <` l ,. Expires:0912812019 OLIVER M KELLY 74 1 BRHINE ROAD, ,.,`/ YARMOUTH PORT MA 02675 $` .mo a w• 10ity 1.i0a. Commissioner V"”' �, int!