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HomeMy WebLinkAboutBld-20-000880 if'YR,,tt 4 Office Use Only 4c { :4t, ! Femrit# , O . l ! .,,Ni Amount S� Permit expires 180 days from 1 B issue date • ��_ �t� li A --...x. EXPRESS BUILDING PERMIT APPLICATI EC V E D TOWN OF YARMOUTH Yarmouth Building Department AUG 16 2019 1146 Route 28 South Yarmouth,MA 02664 B11I- (508) 398-2231 Ex, 1261W aY. ' CONSTRUCTION ADDRESS: t LU IE Luero Id;4-, i3. .144elotgorli ASSESSOR'S INFORMATION: / Map: Parcel: OWNER.L VLeAi. SVA'S OGST etlegee iLAA0 ISO 1 L�A TEL ADDRESS �`' r' i TEL. #�'pg �/Z. �.I�j Z.' CONTRACTOR: k-t-i4 10a-t :1 C- \i .- �, Iluwe. Legvs, '$', iv1 U.6.1"GiP14 Q i7S NAME MAILING ADDRESS .' TEL.#4 r,r 9 b(-(L> H Residential 0 Commercial Est.Cost of Construction$72_00 Home Improvement Contractor Lie.# I OS 9 5-7 Construction Supervisor Lic.# 09 9 /67 Workman's Compensation Insurance: (check one) f 0 I am the homeowner 0 I am the sole proprietor I I have Worker's Compensation Insurance Insurance Company Name:4c64,,,,,e,„2., 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 20 ( At/.)Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at 1 4e LI 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 ford " r ation of my license and fo cution under M.G.L.Ch.268,Section I. Applicant's Sipatur • Date: V ( (5 7 t9 Owners Signature(or attachment) { Date: Approved By. 9 7G�f Building g Date: / al des gnee) ADDRESS: i Zoning District Historical District: 0 Yes ❑ 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 ACC) D CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYTY) 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 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(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 NAME: Linda Sullivan DOWLiNG&O'NEIL INSURANCE AGENCY PHONE,E„tp (508)775-1620 FA" E-MAIL (A/C,No): ADDRESS: Isullivan@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 D: 8 RHINE RD INSURERS: 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 CONDmON 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 ADOL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE 1NSD WVD POLICY NUMBER (MM/DD/YYYY) (MIWOD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GERI AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY ECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ {Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED r AUTOS AUTOS N/A BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE _ AUTOS (Per accident) UMBRELLA UAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED I RETENTION$ $ WORKERS COMPENSATION MUTE EMPLOYERS'LIABILITY ti,�N X STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,000 A OFFICER/MEMBEREXCLUDED? WA N/A WA 6S62UB8H08580919 05/10/2019 05/10/2020 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 N yes,desaibe Under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS I 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.gov/Iwd/workers-compensatioMnvestigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DEUVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. The Barnstable Insurance Company 108 Route 6A AUTHORIZED REPRESENTATIVE Th Yamtauthport MA 02675 ` . 1 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 Commonwealth of Massachusetts 11; Division of Professional Licensure Board of Building Regulations and Standards Construction S'Lpervisor Specialty CSSL-099167 Expires:09/28/2019 OLIVER M KELLY 8 RHINE ROAD,. YARMOUTH PORT MA 02676 Commissioner ,97-4 go-i974n20-i-wwxdie 0-//a /4- Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Individual Registration: 128957 OLIVER KELLY Expiration: 06/13/2021 8RHINERD YARMOUTHPORT,MA 02675 3 £'s'� A Update Address and Return Card. iCA 1 Co 20M-05/17 Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE;Individual Registration Expiration d.6. 06/13/2021 OLIVER KELLY f', The Commonwealth of Massachusetts f _--17- 'l1, Department of IndustrialAccidents t -%,, _ r' 1 Congress Street, Suite 100" _.07 "" Boston,MA 02XX4 2017 �'' ,,=,1 w.wwmass.gov/dia `r Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH TIL,PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organ" 'on/Individual): V\ _L16 Address: S >r. t \4-` City/State/Zip: ""{.M.1\-(0...7114. Pkit O2675Phone#: $O 8- 5 L1 6`ZO Are you an employer?Cheek the appropriate box: Type of project(required): LC}I am a employer with G-- employees(full and/or part-time).* 7. ❑New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.❑I am a homeowner doing all work myself[No workers'comp.insurance required]t 10 0 Building addition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.E1Coof repairs These sub-contractors have employees and have workers'comp.insurance.t 14.0 Other 6.0 We area corporation and its officers have exercised their right of exemption per MGL c. 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. f 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 ' workers'compensation insurance for my employees. Below is the policy and job site information. AE\kit.%--"\a‘Lbt Insurance Company Name:(�,� t� { � ( - Policy#or Self-ins.Lic.#:C S(o L— h "'tf0 tJ5(60 \ Expiration Date: Job Site Address: 'lb Loet 1 a., City/State/Zip: V A 6 Attach a copy of the workers'compensation policy declaration page(showing the policy num er 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 cer' un the pains and en . of perjury . ' o ' a ='on ; , ' above is tru and correct Signature: �0 • q Phone#: Official use only. Do not write in this area,to be completed by city or town official City or Town: PermWLicense# 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#: