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Home My WebLink AboutBld-20-001434 y Office Use Only • 7 • Permit# .:, 0 `" ,► ' J -Amount 4 ' ----..,-_,,_.;,,,-, ..1 h_.0 eiiit i l$o't ys, of .., ,-. EXPRESS BUILDING PERMIT APPLICATIO1 SEP 13 2019 TOWN OF YARMOUTH .,1 ,1 Drr\c � ,.1r: ' 'i Yarmouth Building Department --- =-T - 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 E . 1261 �� -LCJ . CONSTRUCTION ADDRESS: t �,i �N� .� 1�, _ (...f4u2s,ivo j„i_v ASSESSOR'S INFORMATION: Map: Parcel: OWNSa.0,0 t k)`� K\41\) `) e41 , " 9.� t-1{ d 1 NAME�� PRESENT ADDRESS TEL # CONTRACTOR: ILELL 4 ( W C \ -`:-- S Q.U,i tvLPi—CANLtAtAil tU Ut MA V11-7S NAME MAILING ADDRESS TEL.# ,.....:)cc.., � s tr.?Lf b — e Residential ❑Commercial Est.Cost of Construction$(6000 Home Improvement Contractor Lic.# p 9 5-7 Construction Supervisor Lic.# C(19 b 7 Workman's Compensation Insurance: (check one) 7 ❑ I am the homeowner 0 I am the sole proprietor ® I have Worker's Compensation Insurance Insurance Company Name:4C 4frtrLt( 4& Worker's Comp.Policy#( 2 V e75 q 0-U$g Q S i ct WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares 2� ( d//)Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing ./,q*The debris will be disposed of at: � �+�y� e- �` 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 ' cation of my license and fo cution under M.G.L.Ch.268,Section 1. (j Applicant's Signatur -` Date: 9 i 1 19 le Owners Signature(or attachment) Date: q l3 l i . 6. � Approved By: „.I G'\ Date: —1' lcA Building Offici (or designee) EMAIL ADDRESS: 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 ACORO® DATE(MWDDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 05/14/2019 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 (AIC.No.ern: (508)775-1620 FAX ►,,, EMAIL 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 INSURER C: INSURER D: 8 RHINE RD INSURER E: YARMOUTHPORT MA 02675 INSURER F: COVERAGES CERTIFICATE NUMBER: 402283 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 POUCIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTA INSD wvn POLICY NUMBER IMM(DDIYYYYI (MWOD/YYYYI COMMERCIAL GENERAL LIABILITY EACH OCCURRENCEGE TO $ CLAIMS-MADE OCCUR PREMISES(EaoccurDrerece) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea au k rt) ANY AUTO BODILY INJURY(Per person) $ — ALL OWNED SCHEDULED N/A BODILY INJURY(Per accident) $ _ AUTOS AUTOS ON--OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per accident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE— $ — EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTIONS $ WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER Y/N ANYPROPRIETOR/PARTNERIEXECUTIVE EL EACH ACCIDENT $ 500,000 A OFFICERIMEMBEREXCLUDED? N/A WA WA 6S62UB8H08580919 05/10/2019 05/10/2020 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION 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 tithe 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-compensation/investigations/. 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 POUCY PROVISIONS. Town of Dennis - Building Department PO Box 2060-485 Main Street AUTHORIZED REPRESENTATIVE South Dennis MA 02660 ` Daniel M.Croey,CPCU,Vice President—Residual Market—WCRIBMA ®19813-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Ccnstr uc ion Supervisor Specialty CSSL-099167 Expires: 09/28/2019 OLIVER M KELLY 8 RHINE ROAD 4 YARMOUTH PORT MA 02675 Commissioner v *� 67Z 6/71,71/0-/Wielade40, 0:c.loadek)Wki- Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Individual OLIVER KELLY Registration: 128957 8 RHINE RD Expiration: 06/13/2021 YARMOUTHPORT,MA 02675 Update Address and Return Card. SCA 1 0 20M-05/17 Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Individual Registration Expiration 1.28957-_ 06/13/2021 OLIVER KELLY 11 *" . The Commonwealth of Massachusetts t--7_4;.-..-. Department oflndustrialAccidents __bill _' 1 Congress Street,Suite 100 .� Boston, MA 02114-2017 � �� A �`�7, www mass gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information _ Please Print Legibly Name(Business/O L _ 1 rgar►' oa/Individaat): \� �- WQ"..-_ Address: S Ul Vk)L aGQ, City/State/Zip: --( .- O PAykO27Phone#: $0 8 c5Q f q b Lyo Are you an employer?Cheek the appropriate box: Type of project(required): I.❑I am a employer with 2- employees(full and/or part-time).* 7. 0 New construction 2.0 I 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 doingall workt 9. ❑Demolition ❑ myself[No workers'comp.insurance required.] 10[]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.❑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 These sub-contractors have employees and have workers'comp.insurance.* 1 3. Of repairs 6_0 We are a corporation and its officers have exercised their rightof I4.❑Other 152,§I(4),and we have noeel MGL c. employees.[No workers'comp.insurance rerNred-] *Arty 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. *Contractors that check this box mint 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 pr ' workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: et Policy#or Self-ins.Lic.#:6502-1 j (4,0Y5a$0C1 11 Expiration Date: 6 " \.Q Job Site Address:It( � �C)r \\\ C• /State/Zi - (11/44°210(0Y 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 certify under the pains and penalties of perjury that the information pro ' abov is true and correct. Signature: Date: (3 ( Phone#: 50C EO `Cb't,O 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#: