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HomeMy WebLinkAboutBld-20-001175 y Office Use Only �°� �'; `t` Permit# y 4'1 ems: Ol H. Zy Amount • _ "Permit expires 180 days from -°=_,sic_ C)-1,^� I 1 1 J issue date EXPRESS BUILDING PERMIT APPLICATION i 3 2019 TOWN OF YARMOUTH AUG , Yarmouth Building Department 1146 Route 28 -"u,r4, U PA R i c;ir.r� South Yarmouth, MA 02664 _ (508) 3 8-2231 Ext. 1 61 Ut CONSTRUCTION ADDRESS: 3\. SLIAbtaiv .) "l lI 1 C ASSESSOR'S INFORMATION: Map: Parcel: OWNER + S _ 7• * 4' -. %\ )AAft- ' S� �- �8� 1 026�� N SE�Ii F ADD ` �. TEL. ' (C,D bq g Moo CONTRACTOR: !_LL (2.C() tv e GN �. - S P-U 1 � )t "[ AA 0 O)-Ck MA v b`7S NAME MAILING ADDRESS TEL.# E Residential 0 Commercial Est Cost of Construction$ iia 1 L Home Improvement Contractor Lic.if 1,..L 9--7 Construction Supervisor Lic.# C(Iq /6 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(_-, 4frttc4& Worker's Comp.Policy#(). 2 U e7 q u `, o r7 v i WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares 2L{ ( /)Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ('v)Replacing like for like Pool fencing *The debris will be disposed of at qfi' " 1 :a 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 ,, -,.,cation of my license and fo cution under M.G.L.Ch.268,Section 1.tfill �(� i O'�Applicant's Sign•• ; `4 �. 1� Date: t ( ) t 1Owners Signa re(or a I ent) OF° Date: 11 Approved By: y s_ ice/ Date: 9 ` �,5 Building 0 P• 4.x ee) 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 ❑ No The Commonwealth of Massachusetts 1 '/ Department oflndustrialAccidents =R►j= 1 Congress Street, Suite 100 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 ?..sDiz-AP- Cs- Address: Please Print Legibly Name (Business/Organi 'onandividual): y ��t S ktA.Is'u t City/State/Zip:ift-g-ikke0-114. O2 75Phone#: $o 8 q 61jQ 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. I am a homeowner doingall workt 9. ❑Demolition ❑ myself.[No workers'comp.insurance required.] 4.0 I am a homeowner and wrlI be hiring contractors to conduct all work on my property. I will 10 El 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. mese sub-contractors have employees and have workers'comp.insurance.t U. Roof repairs 6.0 We are a corporation and its officers have exercised their rightofexemption14.Q Other 152,§1(4),and we have no ereper]MGL c. employees.[No workers'comp.insurance •] *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. tContrrctors that check this box must attached an additional sheet showing the name of the 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 employee& Below is the policy and job site information. n_ Insurance Company Name: k.Q,u6K1 Policy#or Self-ins.Lic.#:Y.)945 0b O55 CR le( Expiration Date: 6 ' © ' 2 Job Site Address:58 3W\.k )& lJ\f) Q City/State/Zip: 16`2.61C 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 prov' abov is true and correct. Signature: Dater \C\ Phone#: 5CQ1 �Q l'1 Official use only. Do not write in this area,to be completed by city or town offieiat 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#: ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYY`l) 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 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 PH-(A/CON.N_E:t): (508)775-1620 (F ,No): E-MAIL 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 EXPMI LIMITS LTR INSR WVD POLICY NUMBER (MDDIYYYY) (MM/DDJYYTY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCEGE 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/ABODILY INJURY(Per awidtiR) $ 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 VI' PER OTH- AND EMPLOYERS'LIABILITY X STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $ 500,000 A OFFICER/MEMBER EXCLUDED? 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 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 POUCIES 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 Yarmouthport MA 02675 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 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 YARMOUTH PORT MA 02675 Commissioner • 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 e>7...z;-;a6/4:p 4 Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Individual Reaisti tton �xdiration 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 INSURED Aug. 25' 2019 Proposal submitted To Doug Barall of 81 Shaker House Road, Yarmouthport 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) 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$10,000 Payment Schedule; Balance upon Completion Proposal Submitted by: Oliver Kelly Proposal accepted by: �<- Date. g / j /2019 Best Contact Phone Number: This proposal is valid for 45 days from date above, please call to verify thereafter.