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HomeMy WebLinkAboutBld-20-002954 Y ` ` -Office Use Only • $ ' 'y., p O` Permit# ;�, M„ Amount SO ` Permit expires 180 days from - 6 , = " 0 --17)0-1(il V I ;?issue date - EXPRESS BUILDING PERNIIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department '0 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 �" ( CONSTRUCTION ADDRESS: rl'l.J ';I %)k 4AD SO . ‘d(A4)M.04• ASSESSOR'S INFORMATION: Map: 39 Parcel: 12 9 • OWNER: oJa� l(O C,.A o 50d 555 [ A`.57 (2)200(Xwk i !) ••Li_ tl2lS' NAME PRESENT ADDRESS TEL. #7'($ Li/5 c1(9 7 CONTRACTOR: I i t y Q.i .74-t,r)Gr- VKI ..- $ Zia i,1 f ,,141m( L;;?-►.! 1',4,' (31 r9;7:13 NAME MAILING ADDRESS ' TEL.# r.— c-- u i PJ Residential ❑Commercial Est.Cost of Construction$'�)40 1 Home Improvement Contractor Lic.# . h S �? Construction Supervisor Lic.# OCi I 6.7 Workman's Compensation Insurance: (check one) 7 0 I am the homeowner 0 I am the sole proprietor ® I have Worker's Compensation Insurance Insurance Company Name: C 4Mr 1 C 4 Worker's Comp.Poll # ' ^ 5 's , WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roof ing: #of Squares Z` a�( )Remove existing*(max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at ''."1 :� i )S elL. 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 .ation of my,Gcense and fo cation under M.G.L.Ch.268,Section 1_ Applicant's SiEnat,u -` Date: Ll ( L I Owners Signature(or attachment) Date: / 1 Approved By: Date: /,-2 G—1 Building Offi • or _ ee) EMAIL ADD S: 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 _ ,r �l Department of Industrial Accidents • 1 Congress Street,Suite 100 '?��E= � Boston,MA 02114-2017 " 410 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/Organi ion/lndividual):. j- Address: Ph #City/State City/State,/Zip: ne : 30% 509 4 Are you an employer?Check the appropriate box: Type of project(required): 1.{am a employer with t employees(fun 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. 0 Remodeling any capacity.[No workers'comp.insurance required.] 9. 0 Demolition 3.01 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 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 arc 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.[ oof 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 exemp ion per MGL c. 14.0 Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#I 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 alike 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 prov ding workers'compensation insurance for my employee& Below is the policy and job site information. Insurance Company Name: ..t: DI-C\A):SCI lU Policy#or Self-ins.Lic.#: (C) � .2_.\3 'J hOS i)U 1p ration Date: S • I 0- Job SiteAddress:70 ct-LS C2.040 City/State/Zip: �.04I,Lf), 'N ILf 9 ©2 .J Attach a copy of the workers'compensation policy declaration page(showing the policy n her and expiiation date). Failure to secure coverage as required under MGL c. 152,j25A 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 hereb t:der the pains and pare perjury that the information provided above is true and con- t. g /Signatu . � Date: L j Phone#:(9R) c 30 104,0 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#: grZ Ko-n-mno-impeadi 6)4 a44exc itic -e//,,.a- 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 C' 20M-05/17 �l .ff m,iirn/ c n /12e6:,;arlha ll 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: Registration Expiration Office of Consumer Affairs and Business Regulation 128957-- -- 06/13/2021 1000 Washington Street -Suite 710 OLIVER KELLY Boston,MA 02118 OLIVER M.KELLY. r-> \ Q 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:09/28/2021 OLIVER M KELLY 8 RHINE ROAD YARMOUTH PORT MA 02675 Commissioner Al,echos tc ce rerovec i0 town ransier !lr to A.,'nin.,m Chip Edge tc be nstafied or all eaves and Rakes re anc Wale'darrage protection mnemorane to be irstalled on first S x feet of al+eaves it all vai;ty areas and around al!t:rotnsions_ Remainder of roof deck to be covered with synthetic cnderiayment Instal li' tec itetirne wctrrar y Architect stv=e Shingles color to Ce scecifie d Ali Sr,inq,Ac tc storm nailed iF iWe C"Gene-ally Use Cerlairtanr.Prr ucts with Al,Ar.es ;iri+?s to maximize available warranties.This quote is Based on T^,e Regular-Architect"Sty -andmari. Series Shingle Replace plumbing vent pipe boots with r'>nw Repair., Replace ali fleshings as necessary. Ingle Veeret It r.cge vent with hared r aliutrt cape LLri ilele:Glean u; of' all areas irclud•'-:q al gutters and al nails ant-,pro ect complete At a tote cos!of$7 95C Pa,ren'Scredule. Balance upor Uurnplencin rose Submitted by Oliver Ke y Acceptable please sip^ and;ratan a copy to the address above. '14.64e• nC 4' / ' apse accepteC by' Date 2019 'te st r (;cica is valid fiv di lays'rnrr late above please cal 'c verfy thereafter Best Co-tact into. From: Youri Podchosov koneuka@gmail.com Subject: Re: 70 Davis Road, So, Yarmouth Date: Nov 16, 2019 at 6:45:39 PM To: Oliver Kelly kellyroofing@icloud.com Cc: Olga (GMail) opoddubnaya.bootsoft@gmail.com Hi, Oliver. Please find attached the signed proposal. As we discussed over the phone, please let us know the date as sson as you have the work scheduled, preferably some time between Wed 11/13 and Sat 11/16. Thank you! Youri Podchosov -- 718-415-4199 On 11/13/19 1:35 PM, Oliver Kelly wrote: Youri, Please see a proposal for your roof replacement below, Regards, Oliver Kelly Sent from my iPad KELLY ROOFING PH 508 509 484:; A R ing Roac MA C S . # raq•;.- Yar^ioutiport MA H. ;;.R = 128957 MA )267 Nrnernhe, 1? ?01r. Procosa subr^Rtec to Mr Your P dscioso‘ of ;:; cad, Sour Yarmouth MA We Jr',t*_r si,f lily a i rnawi ala anr. lar•,ny rr+q..irnn•n rt - iv'ark', - pia.- the ex sting asprall rcof at'he address at eve Pro'ec!ai wa is W ndoors siruns p.a^ts etc d,Jr ng r;o`s'r!p ACORD CERTIFICATE OF LIABILITY INSURANCE DAo(MMI DW Y 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 requite an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER N CONTACT Linda Sullivan DOWLING&O'NE)L INSURANCE AGENCY piallo.Ex,,: (508)775-1620 FAX (A/C,No): E-MAIL proms: Isullivan(gdoins.com 973 IYANNOUGH RD INSURER(S)AFFORDING COVERAGE NAILS 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. NOTIMTHSTANDING 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 POUCY EFF POUCY EXP LTR TYPE OF INSURANCE INSp wvD POUCY NUMBER IMMIDWYYYY) (MMIDI YYYY) LIMITS COMMERCIAL GENERAL UABILITY EACH OCCURRENCEDAMAGE TO $ CLAIMS-MADE OCCUR PREMISES(EaENTED ocasrence) $ MED EXP(Any one person) $ N/A PERSONAL 8 ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO LOC PRODUCTS-COMP/OP AGG $ PRO- JECT OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) — ANY AUTO BODILY INJURY(Per person) $ ALL OWNED — SCHEDULED N/A BODILY INJURY(Per accident) $ — AUTOS AUTOS ON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS (Per accident) UMBRELLA UAB _ OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTIONS $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY X STATUTE ER EACH ACCIDENT $ 500,000 A OFFICER/MEMBERPEXCLUDED? IVE WA WA WA 6S62UB8H08580919 05/10/2019 05/10/2020 E.L. (Mandatory in NH) EL.DISEASE-EA EMPLOYEE $ 500,000 I desaibe 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 I 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/iinvestigations/. 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( Daniel M.CrC y,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