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HomeMy WebLinkAboutBld-20-001368 ,Af.„..:Ylk44,.- IcAre-X-(77)/36" 1• 0, ,y c: s . �.,_ a `�1 `�t�� .yH j Amount • `- w�Tr n - '+ li 1 = l Permit expires 180 days from _-._ issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 2 508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: iti �6r Q-Q,2 ` 6sNiz:(1,1 C).b t ASSESSOR'S INFORMATION: Map: L.tiO Parcel: t3 OWNER:QlWAQ4 biNALNAA Lt1 �} ��6 5 11\) ' r�J �� - 02171.5 NAME PRE ENT ADDRESS $ ,�r�I CONTRACTOR: iLH (t v_th C,"' �, - �? 1 U 19J1 0.61-.k A: C 1 b 7S NAME MAILING ADDRESS TEL.#50 so-er 4-1.b6 ,.o 1J Residential 0 Commercial Est.Cost of Construction fit`ba) 'i Home Improvement Contractor Lic.# !-..CC 9 5 7 Construction Supervisor Lic.# 9 i b 7 Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor 4have Worker's Compensation Insurance Insurance Company Name:4C6 4A,,,r_ c,,(141/41. Worker's Comp.Policy#44)21.)erogoSSg 0 g t Cr WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares n Replacement windows:# Replacement doors: # Roofs g: #of Squares 1,.1 ( r/ )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like fo like Pool fencing q 1441.1\111GUs4:A Z. *The debris will be disposed of at { atux,l,G Location of Facility I declare under penalties of perjury that the .1 , its herein contained are' and correct to the best of my knowledge and belief. I understand that any false answer(s) will be just cause ford •,gation o n •• nse and fo cu'.. der M.G.L.Ch.268,Section 1. Applicant's Signature _ t� _ - i Date: q ( lli c) Owners Signature(or attachment) jf Date: Sr If "20,6 9 Approved By: -� Date: 7---- 7 I7/ j.•r' 2;097 (• designee) E .'.''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 The Commonwealth of Massachusetts _„, f'/ Department of IndustrialAccidents ?err ,-y 1 Congress Street,Suite 100 t Boston, MA 02114-2017 r`t wwr�.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/Organi on/Individual): \� \ LQ_ Address: S t4tA.vv.) \ City/State/Zip: ,/ . 114O2 75Phone#: 5©S 500( L16 Zo 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-time).* 7. 0 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.] 3.0 I am a homeowner doing all work myself[No workers'comp.insurance required.]t 9. ❑Demolition 10 0 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 11.0 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. 13.�Roof repairs These sub-contractors have employees and have workers'comp.insurance .t 6.0 We are a corporation and its officers have exercised their rightofexemption 14.0 Other per MGL c. 152,§1(4),and we have no employees.[No workers'camp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. I 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 pro ' workers'compensation insurance for my employees. Below is the policy and job site information. n_ Insurance Company Name: VGA T)kf\\ _ Policy#or Self-ins.Lic.#: SUS612--COb 40 5 O L n Expiration Date: 6 ~ O Job Site Address:. `. ' QQ.Nk-C- tA\.6 jN�,i`,R ) City/State/Zip: eb t`{%n MA 0 .67c 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 c� Signature: Date: Phone#: 50TC 3OCI LQ O l 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#: TE ACCORD CERTIFICATE OF LIABILITY INSURANCE DA07/02/2019 Y) 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 P ",� ,: (508)775-1620 (A/C Fla 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 INSURER C: 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 LTRINSR WVD POLICY NUMBER (MMND/YYYY) (MWDD'YYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCEDAMAGE TO $ CLAIMS-MADE OCCUR PREMISES(EaENTED occur err,) $ MED EXP(Any one person) $ N/A PERSONAL 8 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 w N/A BODILY INJURY(Per aJert) $ _ _ NON-OWNED PROPERTY DAMAGE HIRED AUTOS _ AUTOS (Per accident) UMBRELLALIAB _ OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION V PER OTH- AND EMPLOYERS'LIABILITY I� STATUTE ER Y/N 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 Yarmouthport MA 02675 �w (`) Daniel M.CroVey,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 g77- ze OT/1/112,6242,10eC2a .kal",14e46 3 • . k=1, Office of Consumer Affairs and Business Regulation 10 Park Plaza- Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Type: Individual Registration: 128957 OLIVER KELLY Expiration: 06/13/2019 8 RHINE RD YARMOUTHPORT,MA 02675 Update Address and return card. Mark reason for change. SCA I Cr 20M-05/11 Afirlrocte n D . wql n=“1,11101/Mtanilli in0 Card r ',re((//a 741 JI(te /I A(41:1 Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE Individual before the expiration date. If found return to: .81 Registration Expiration Office of Consumer Affairs and Business Regulation 128957 06/13/2019 10 Park Plaza-Suite 5170 OLIVER KELLY Boston,MA 02116 OLIVER M.KELLY 8 RHINE RD. YARMOUTHPORT,MA 02675 Undersecretary _ Not valid without signature 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 Ito 8 RHINE ROAD YARMOUTH PORT MA 02675 Commissioner CL 7" 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 fi Commissioner • �4 WO-fir4MO/ e(}eKg140-/��� Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Individual E Registration: 128957 OLIVER KELLY 8 RHINE Expiration: 06/13/2021 YARMOUTHPORT,MA 02675 Update Address and Return Card. SCA 1 C' 20M-05/17 .//c Kanvraonupra n fl9.4i2c cie/L-i Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Individual Registration Expiration 128957- - 06/13/2021 OLIVER KELLY