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HomeMy WebLinkAboutBld-20-000881 -oi•Y'` Office Use Only g }; SO 'Permit# Q "7"`it .H Amount �V ' �9 k.o.nsso ',E' Permit expires 180 days from f.. ' bcb-ao----s+1issue date RECEIVED EXPRESS BUILDING PERMIT APPLICATI N TOWN OF YARMOUTH AUG 16 2019 Yarmouth Building Department s -n- 1146 Route 28 South Yarmouth,MA 02664 (508) 398-223 Ext. 1261 ADDRESS: CO-A-1\1Ce� V �`, J ikCONSTRUCTIONqaaikk,61)Vti ASSESSOR'S INFORMATION: Map: Parcel: OWNER: 1 Pr:S (LgQ&i� (16 ac D2bJ f NAME PRESENT ADDRESS TEL. # 5p�S c .jp2_ `fir ; N �. P .J MA 4J `S CONTRACTOR: tires-Lt.� i$.{ �-1.v�,i� ��`�,�- 1�.ijk 115i� �� '��,�� /� NAME MAILING ADDRESS s TEL.#4 ,-.3 SO,., b J Lf Residential 0 Commercial Est.Cost of Construction$4 0- 0 Home Improvement Contractor Lic.# I q 9 5- Construction Supervisor Lic.# C)9 9 I Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor ai I have Worker's Compensation Insurance Insurance Company Name: Ci 4 t 1 C' '. Worker's Comp.Policy# 42()( t4 C 6g o gi? WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofin •• #of Squares 1t ( /)Remove existing*(max.2 layers) Insulation V Old Kings Highway/Historic Dist. ( Replacing like for like Pool fencing 7 *The debris will be disposed of at: '1 1 l` =1! 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 ' re ation of my license and fo . -cution under M.G.L.Ch.268,Section 1. Applicant's Signatur . I► Date: (6 15 I Ape Owners Signature(or attachment) _ -- Date: 46'"`1,4,A Approved By: Date: ��j71 Building or. ignee) EMAIL SS: 7' 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 A =' ff/, Department of Industrial Accidents 1 Congress Street, Suite 100 R _` ';_ '" Boston,MA 02114-2017 .' www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH TI3i PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/O onilndividual): KG.,t A I c2.3D-CiP\k3Cr Address: S t�l INV `i City/State/Zip: .; 'O24 Phone#: 5°8- 5b LI 6 tQ Are you an employer?Cheek the appropriate box: t7 Type of project(required): LEI1 am a employer with ,-- employees(full and/or part-time).* 7. ❑New construction 2.Q 1 am a sole proprietor or partnership and have no employees working for me in 8. El Remodeling any capacity.[No workers'comp.insurance required.] 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required]t 9. ❑Demolition 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.❑Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.0We are a corporation and its officers have exercised their right ofexemption per MGL c. 1$ Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that cheep box#1 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. tContractors 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 pro ' ing workers'compensation insurance for my employee& Below is the policy and job site information. Insurance Company Name: rx Policy#or Self-ins.Lie.#:65(62-06C6LVA5601 Expiration Date: Job Site Address: cQ4C ) 1,1 City/State/Zip: � �� '' 0 bT Attach a copy of the workers' compensation policy declaration page(showing the policy number and expin'ation 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 certify under the pains and penalties of perjury that the information prov' abov is true and correct Signature: Date is I Phone#: C. � 5° -1,O.4,0 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): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: r ) H DATE(MM/DD/YYYY) ,AR L� CERTIFICATE OF LIABILITY INSURANCE 07/02/2019 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(ies)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 Linda Sullivan DOWLING&O'NEIL INSURANCE AGENCY PHONE No.Ext.): (508)775-1620 FAX is ,No>: DORESS: Iullivan@doins.com 973 IYANNOUGH RD INSURER(S)AFFORDING COVERAGE NAIC# HYANNIS MA 02601 INSURER A: ACE AMERICAN INSURANCE CO 22667 INSURED INSURER B: KELLY ROOFING INC INSURERC: INSURER O: 8 RHINE RD INSURER E: YARMOUTHPORT MA 02675 INSURER F: COVERAGES CERTIFICATE NUMBER: 420827 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 ADDL SUBR POLICY EFF POLICY EXP • UNITS LTR TYPE OF INSURANCE INS° WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY). COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEM_AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ PRO- I POLICY JEC7 I LOC PRODUCTS-COMP/OP AGO $ $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) BODILY INJURY(Per person) $ — ANY AUTO ALL OW _NED SCHEDULED N/A BODILY INJURY(Per accident) $ AUTOS — AUTOS PROPERTY DAMAGE NOON-OWNED (Per accident) $ _ HIRED AUTOS r-• AUTOS $ UMBRELLA LUAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ WORKERS COMPENSATION X PER ERH AND EMPLOYERS'LIABILITY IV N ANYPROPRIETORIPARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,000 A OFFICERIMEMBEREXCLUDED? WA N/A N/A 6S62U138H08580919 05/10/2019 05/10/2020 E.L.DISEASE-EA EMPLOYEE $ 500,000 (Mandatory in NH) - E lf yes,describe under E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS below N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached it more space is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WG 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/lwdlworkers-compensationrnvestigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. The Barnstable Insurance Company 108 Route 6A AUTHORIZED REPRESENTATIVE MA 02675 C Yarmouthpart Daniel M.Croy,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 g."1- .4e (Cotillifiwzite/ittea&A t9/ ' Office of Consumer Affairs and Business Regulation 10 Park Plaza- Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Type: Individual Registration: 128957 OLIVER KELLY Expiration: 06/13/2019 8 RHINE RD YARMOUTHPORT,MA 02675 Update Address and return card. Mark reason for change. SCA 1 Cs 20M-05/11 11 Arlilrfine r_i GenowAl l FmralnumAnt n I. Card 1/e ` ontiitoirt.real44 oADil/, ,..l-r.113 Office of Consumer Affairs&Business Regulation —==y z HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only t TYPE:Individual before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation y�� 4 128957 06/13/2019 10 Park Plaza-Suite 5170 O IVER KELLY Boston,MA 02116 OLIVER M.KELLY ,-c-c.0 --- _� ? f-_ = ' _-`-.- ..4 — -- 8 RHINE RD. a"_ Not valid without signature YARMOUTHPORT,MA Q2675 Undersecretary�--_ Commonwealth of Massachusetts 11 Division of Professional Licensure Board of Building Regulations and Standards Constructica s:Supe visor Specialty CSSL-099167 EZpires:09/28/2019 OLIVER M KELLY _: . 8 RHINE ROAD ,. { YARMOUTH PORT MA 02675 '- Commissioner 'urn.