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Home My WebLink Aboutbld-20-000516 7y4.4 O -dice Use Only Permit# fa : '_i ► -, Amount .yeti' ., 4°""°`°"* ` � 'Permit expires 180 days from 1 issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH {r ; Yarmouth Building Department 1146Route28 c ot- South Yarmouth,MA 02664 p`(508) 398-223 Ext. 1261 CONSTRUCTION ADDRESS: ` i� 'M I�LIJ c {'-,'-- ASSESSOR'S INFORMATION: Map: Parcel: OWNER: 1 V �,(1Q0 VI�5—1 �� zIliz_216) a. . . Q2NAI P} ENT ADDR TEL # ,�_ � $Og 367v35� CONTRACTOR: t].i:�i.I \C 1:t.Y.\i\r \, - S 1Zi.11 aE 11 qAtivt O iy'r MA v b'7 S NAME MAILING ADDRESS TEL.#t :•�• S'CJ Gl bli LJ iltresidential ommercial Est.Cost of Construction$,S-p.ggj il Home Improvement Contractor Lie.# l j`-' 1 5�7 Construction Supervisor Lic.# V c7 q l b 7 Worlanan's Compensation Insurance: (check one) , 0 I am the homeowner 0 I am the sole proprietor i I have Worker's Compensation Insurance Insurance Company Name: 4C /1ly„,...,C4-& Worker's Comp.Policy# 20(7 g0S5g fig!? WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares i Re lac cent wwindo�ys Replacement doors: # Roofing: #of Squares /t7 Remove (max.2 layers) Insulation 9 ( ) existing* y ) Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing t., *The debris will be disposed of at 1" 1 :' +G .. 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 de . re tion of my,license and fo ecution under M.G.L.Ch.268,Section 1. Applicant's Signatur : _ ^ Date: 7 ( 2q I t9 Owners Sign a(or attachm Date: Approved By: Za-- Date: ding 0 ial(or designee) EMAIL DRESS: 7 3/—/ Zoning District: Historical District: :F Yes 0 No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes = No 0 Yes D No The Commonwealth of Massachusetts It= ffl, Department of Industrial Accidents et ji1=p 1 Congress Street,Suite 100 ..-z.s: Boston,MA 02114-2017 ._ 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/Orgut) ization/Indiv idual : IAY\.E 2OQ )3(s to L Address .UA, € R s City/State/Zip: N10,6 MA O 75 Phone#: 50 % 50 i Li Ci_ 4 0 Are you an employer?Check the appropriate box: Type of project(required): 1.[Ril am a employer with 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. 0 Demolition 3.❑1 am a homeowner doing all work myself.[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 0 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet. ❑ 13.[a-koof repairs These sub-contractors have employees and have workers'comp.insurance.= 6.0 We are a corporation and its officers have exercised their right of exemption per MGL C. 14.0 Other 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. 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: AC . � ,(\/,2\- 1,t� .,. K 1 . Policy#or Self-ins.Lic.#: b5b 6 CAI)O S Oc( t9 Expiration Date: Ca' ° 2-0 Job Site Address: !L ,VO, UV City/State/Zip: 0266(1 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 • nde the pain and per a! s of p1erjury that the information provided above is true and corre t. Signature: Date: 7 �7 C 11 Phone#: _ -U cc t 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#: Commonwealth of Massachusetts III- Division of Professional Licensure Board of Building Regulations and Standards Construction Supervisor Specialty CSSL-099167 Expires: 09/28/2019 OLIVER M KELLY 8 RHINE ROAD tef. „ s YARMOUTH PORT MA 02675 Commissioner C/- ~'► • ram,nonzioeall l�/� L2 c)-cciu4 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 C/ / J Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Individual Registration Expiration 28957 06/13/2021 OLIVER KELLY • A Rd DATE(MMIDO/YYYY) o7(MM CERTIFICATE OF LIABILITY INSURANCE /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(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). PRODUCER CONTACT NAME: Linda Sullivan DOWLING &O'NEIL INSURANCE AGENCY PHONE c.1i,Ext): (508)775-1620 F X,Noy: 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 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMBS LTR INSD WVD POLICY NUMBER IMM/DWYYYY) IMMIDWYYYYI COMMERCIAL GENERAL LIABIUY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ 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 accident) ANY AUTO BODILY INJURY(Per person) $ - ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per ew,llntF) $ _ _ NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS _ AUTOS (Per accident) UMBRELLA UAB _ OCCUR EACH OCCURRENCE $ - EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X Y/N PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,000 A OFFICER/MEMBER EXCLUDED? WA 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 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-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 POLICY PROVISIONS. The Barnstable Insurance Company 108 Route 6A AUTHORIZED REPRESENTATIVE 95c- Yarmouthport MA 02675 '" CL Daniel M.Cro4ov ey,CPCU,Vice President—Residual Market—WCRIBMA 1988-2014 ACORD CORPORATION. Ail rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD r