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HomeMy WebLinkAboutBld-20-001595 Y Office Use �Onllyy/�J) fr- Amount�n „s ;Permit expires 180 days from `--'r; ;i issue date EXPRESS BUILDING PERMIT APPLIC 'IRIBIS E ! V E TOWN OF YARMOUTH �` Yarmouth Building Department SEP 90 2019 1146 Route 28 South Yarmouth, MA 02664 PAR-4 (508) 398-2231 Ext. 1261 $ H CONSTRUCTION ADDRESS: IAVtAia4.4.9--0 SD "AA--(2_nk‘..1.5\--1A ASSESSOR'S INFORMATION: Map: Parcel: OWNER v�0 \� vS� C�0 SO- 1 "UT ®oj tok1 NAME P SENT ADDRESS TEL. # '"7 2(Z 3 g(c)5 CONTRACTOR: II..A.Lt (2,O) tiO Q ‘ -- ' Ida 1 al:,LOAN LtANW 0 V)-(A MA el).b'7 NAME MAILING ADDRESS TEL.ti .J s rJ c.f ,,�bs ,.cj t°J Residential ❑Commercial Est Cost of Construction$cScL�J `-t Home Improvement Contractor Lic.# 1.-)9 5-7 Construction Supervisor Lic.# ©c7 9 r b 7 Workman's Compensation Insurance: (check one) / 0 I am the homeowner ❑ I am the sole proprietor g I have Worker's Compensation Insurance Insurance Company Name:4CF 4Myic.4-, Worker's Comp.Policy#F�`-'��G U("7)''7 is t,g 0 g 1 ct WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares /6 ( /)Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at i - CA-1 t 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 ford re,'cation of my license and focution under M.G.L.Ch.268,Section 1. Applicant's Signature• _ 1AP. 1 .r Date: Cl ( ZU i /1 Owners Signatu (or att. hment) dr- Date: 71 / Approved By: - 'Le. y Date: 9' e T 5 Building Oita : •.A) - 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 Commonwealth of Massachusetts V' Division of Professional Licensure Board of Building Regulations and Standards Construction Supervisor Specialty CSSL-099167 Expires: 09/28/2019 OLIVER M KELLY 11 8 RHINE ROAD ,411, YARMOUTH PORT MA 02676 Commissioner • �� Kt-/--iw-nyo-/-4(oeadi 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 is 20M-05/17 K / 16 7/1 Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Individual Registration Expiration 128957 06/13/2021 OLIVER KELLY The Commonwealth of Massachusetts 1" �ti 1- Department of IndustrialAccidents 1 Congress Street,Suite 100 .14 _; �_ 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(Bhrsiness/O on \/Individual): y \� ^ �-- Address: S 1.1 tAv a QA City/state/zip:qA-omw-1-1) -O2 75 hone#: $©g q 6 qo Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with 2- employees(full and/or part-timer 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.] 3. I am a homeowner doingall work 9. ❑Demolition ❑ 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 ❑Building addition 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.t 13.�RoOf repairs 6_0 We are a corporation and its oicers have exercised their " of 14.❑Other 152,§1(4),and we have no employees.[No workers'comp. e MGL c. insurance required.] *Airy 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. lithe 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. n . Insurance Company Name: �-�G AMiCe-T}Ati Policy#or Self-ins.Lic.#:'U5(0 2.1)Pj1614,0 `,—{ Expiration Date: ' \.© _ Z.)� Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy nu ber and exp. lion 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 • the pains an i '.. . of perjury that the information pro ' abov is true and correct Sianatur • VA Date > ( 04) 11 Phone#: 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): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: A RD CERTIFICATE OF LIABILITY INSURANCE DATE 5(MMID /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 NAME; Linda Sullivan DOWLING&O'NEIL INSURANCE AGENCY AI,PHONE , (508)775-1620 ;"<c,►w, ADDREss: Iullivan@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: 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 POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (Min IJYYYYI (MWDD/YYYY) UNITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCEGE TO RENTED $ CLAIMS-MADE OCCUR PRREMISES 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 UABIUTY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ — ALL OWNED .— SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per accident) $ _ NON-OWNED PROPERTY DAMAGE _ HIRED AUTOS _ AUTOS (Per accident) UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X g ATUTE OTH- ER AND EMPLOYERS'UABILITY EACH ACCIDENT $ 500,000 O A OFFICER/MEMBER EXCLUDED'XECUTIVE N/A WA WA 6S62UB8H08580919 05/10/2019 05/10/2020 E.L. (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 0 yes,describe under DESCRIPTION OF OPERATIONS below EL 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-compensationfinvestigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Dennis - Building Department ACCORDANCE WITH THE PoucYPROVISIONS. PO Box 2060-485 Main Street AUTHORIZED REPRESENTATIVE South Dennis MA 02660 Daniel M.CroYeey,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 KELLY HOOFING PH. 508 509 4640 8 Rhine Road MA C.S.L.#099167 • Yarmouthport MA H.I.C.R.#128957 MA 02675 INSURED Aug. 23' 2019 Proposal submitted To Nancy Fuoco of 19 Harvard Street, South Yarmouth MA We propose to supply all materials and labor required to remove and replace the existing Asphalt roof at the address above. Protect all walls, Windows, shrubs, plants etc. during roof strip. All debris to be removed to town transfer. White Aluminum Drip Edge to be installed on all eaves and rakes All Roof Decking Secured Ice and Water damage protection membrane to be installed over first six feet of all eaves and around all protrusions Remainder of Roof Deck to be Covered with Synthetic Underlayment Install Certainteed Landmark limited lifetime warranty Architect style Shingles, Using all Certainteed Starters and Cap Shingles to maximize available warranties, (Color to be Specified) All shingles to be storm nailed (6) j-TI K} N Td C I Ids Repair all flashings as necessary including Chimney. Install Certainteed Filtered ridge Vent on All Ridges with hand Nailed Caps Replace all Plumbing Vent Pipe Boots With new. Complete Clean up off all areas including all gutters and all nails after project complete. Obtaining Of Town Permit At a total cost of$5900 Payment Schedule; Balance upon Completion Proposal Submitted by:Oliver Kelly Proposal accepted by: '-/;00YF1#j e!`CA 1 0 Date. g / 2019 - Best Contact Phone Number: jdorner: Sok-3gr=7� � (eCi! 77(f=02ij-(11Sg This proposal is valid for 45 days from date above, please call to verify thereafter.