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Home My WebLink AboutBld-20-000473 �A A Othce Use Only 3 Permit* �..ve c ��_�_ ' *'' Amount so_ .uriice+ cs r„ �` °`°� d 'Permit expires 180 days from issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH itiL Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 LA(508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: C l2nn- ASSESSOR'S INFORMATION: Map: eN2-0OWNER: C.A0k) �1 C—L)( ,'��`S V ' NAME SO. (q4bil-k,g)\—lk 02aftr PRESENT ADDRESS TEL. CONTRACTOR: ��H (2,0::ft=tk.1 ll k fit (`2A Atkot O'014, MA V �.S NAME MAILING ADDRESS TEL.# S c et '44 bg , fl Residential 0 Commercial Est.Cost of Construction$5 0 `i Home Improvement Contractor Lic.# t Construction Supervisor Lic.# V p7 C/ 167 Workman's Compensation Insurance: (check one) 7 0 I am the homeowner ❑ I am the sole proprietor 8 I have Worker's Compensation Insurance Insurance Company Name:4(;r 4 1y„..1( �IV Worker's Comp.Policy#(), 2UP1$goSSgogi? WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofmg: #of Squares ( �/ )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: 4"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 de re cation of my license and fo ecution under M.G.L.Ch.268,Section 1. • Applicant's Sienatur� � Date: 7 z ( I � Owners Signature(or attachment) Date: Approved By: Date: Build' or des'_ ee) EMAIL ADD . Zoning District: Historical District: 0 Yes ❑ No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: Yes 2 No 0 Yes 0 No The Commonwealth of Massachusetts Department oflndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 "s�•`'� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH TUE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): L ��.� t,t3 (y Address: cS iLAA.toe City/State/Zip: LI p„3'M0 4" aAV O�°�Phone #: 50 s 509 L 17 L( Are you an employer?Check the appropriate box: Type of project(required): 1.i am a employer with 2 employees(full and/or part-time).* 7. New construction 2.❑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. [am a homeowner doing all work myself. 9. ❑Demolition ❑ ys [No workers'comp.insurance required.] 4.❑I am a homeowner and will be hiring contractors to conduct all work on mYproperty. 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.Q Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13 pp f repairs These sub-contractors have employees and have workers'comp.insurance.- uu 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑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-conuactors 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. Insurance Company Name: Qr C ti Policy#or Self-ins.Lic. #: U 5 201N55V, C)i55S oet Expiration Date: S - k.© 20 Job Site Address: 3 ----274: `s.-- `�`Q- City/State/Zip: ; p � Q711 02410 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 S250.00 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 provided above is true and correct. Signature: Date: -7 al ( 2.o tcl Phone#: % 60° Lklotit) 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 Division of Professional Licensure Board of Building Regulations and Standards Construction Supervisor Specialty CSSL-099167 Expires: 09/28/2019 .11 OLIVER M KELLY 8 RHINE ROAD r ' YARMOUTH PORT MA 02675 Commissioner C/16- t6 &/2-km/ G14 0/G � �iG (%L2-44acie(A-e/4- 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 as 20M-05/17 C/ Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Individual RRegist ati0n Expiration 128957 06/13/2021 OLIVER KELLY KELLY ROOFING PH. 508 509 4640 8 Rhine Road MA C.S.L.#099167 Yarmouthport MA H.I.C.R. # 128957 MA 02675 July 23'2019 INSURED Proposal submitted to Carol Coverly Of 3 Banister Lane South Yarmouth MA. We propose to supply all materials and labor required to remove and replace the existing asphalt roof on all front roof areas at the address above Protect all walls, Windows, shrubs, plants etc. during roof strip. All debris to be removed to town transfer. 8"White Aluminum Drip Edge to be installed on all eaves. Ice and Water damage protection membrane to be installed on first Six feet of all eaves in all valley areas and around all protrusions. Remainder of roof deck to be covered with synthetic underlayment.. Install limited lifetime warranty Architect style Shingles, color to be Weathered Wood All shingles to be storm nailed (6) We generally use Certainteed products, this quote is based on their Standard Landmark Limited lifetime warranty shingles. Using Certainteed Starter Strips And Cap Shingles to Maximize Available Warranties. Replace any plumbing vent pipe boots with new. Repair/Replace all fiashings as necessary including. Install Certainteed Filtered Ridge Vent with hand nailed caps. Complete Clean up off all areas including all gutters and all nails after project complete Obtain Town Work Permit At a total cost of$5900 Proposal Submitted by: Oliver Kelly Proposal accepted by: � QJ Date. o 7 / 05 /2019 This proposal is valid for 45 days from date above, please Call to verify thereafter. CAROL J cO V tJ r?LY' Accmr, DATE(MMIDD/YYY1r) CERTIFICATE OF LIABILITY INSURANCE o7(M /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 (PHCNNo.Ext): ,Ext): (508)775-1620 FAX (A/C, E-MAIL ADDRESS: IS U I Iiva n ycyd Oi ns.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 LIMITS LTR INSR WVD POLICY NUMBER (MMIDDJYYYY) (MUMMY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCEDAMAGE TO $ CLAIMS-MADE OCCUR PREMISES(EaENTED 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 accident) $ 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 MUTE EMPLOYERS'LIABILITY STATUTE ER Y/N 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 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 It 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 The Barnstable Insurance Company ACCORDANCE WITH THE POLICY PROVISIONS. 108 Route 6A AUTHORIZED REPRESENTATIVE Yarmouthport MA 02675 =) C`)s Daniel M.Crt vl ey,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