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HomeMy WebLinkAboutBld-20-003725 Mes,ti Office Use Only ..1 A r.�- O Permit# 1. ,, 'yam c ....Office S« — Amount ww7run cs �= �` .a" s d f Permit expires 180 days from !i issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 13u.. -20---3 7Q 1146 Route 28 co:143N- ,S South Yarmouth, MA 02664 ---] (5 08) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: t v.. [ij) SD. q41-12-kiatik. ASSESSOR'S INFORMATION: Map: Parcel: ��` � OWNER � U LtS LAWY4i)8 ti2) a-2v JTCVO MvJ QZ(,b( NAME PRESENT ADDRESS TEL # n , QN lam_ (6 Q` 1` <y ;r�/ c i 7S CONTRACTOR <��H r�t�s•irk V a 1 a;l,:. t�� -1�F,�v��-►.1 NAME MAILING ADDRESS TEL t Residential 0 Commercial Est.Cost of Construction&CO Home Improvement Contractor Lic.# !,) 9 5-7 Construction Supervisor Lic.# CIc C 16'7 Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor �f I have Worker's Compensation Insurance Insurance Company Name:4Cj Worker's Comp.Policy# qU 5b 0 i WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofmg: #of Squares 10 ( {/ )Remove existing*(max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing 1.1*The debris will be disposed of at '. -t 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.-, re \ration ofmy,license and fomiii-cution under M.G.L.Ch.268,Section 1. Applicant's Sigpdjur.• _ 1.w k Q. 1 �'�i Date: 4 (0 t Owners Signatu (or attac I y ent)-,__ __ Date: (p. 7p—j,�j Approved By: , ��� � �� Date: / Z O z° :.,Z a o j 1116. rr'Tr,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 0 No The Commonwealth of Massachusetts ) --'t Department of Industrial Accidents • " = _ ' 1 Congress Street,Suite 100 _';Ti=cy Boston,MA 02114-2017 r - .yr:L�:sy www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly LL1 ) n Name(Business/Or iyation/Individual): `� tl t Address: g Q0 . City/State/Zip ADAW IAA CDSZS Phone#: b4.0 Are you an employer?Check the appropriate box: (� Type of project(required): t.{am a employer with ` employees(fun and/or par-time).* 7. 0 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.] 9.3.0 tam a homeowner doing all work myself.[No workers'comp.insurance required.]t ❑Demolition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. t 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. 13.[3 of 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 exemption per MGL e. 14.0 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-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. l am an employer that is pr idrng workers'compensation Insurance for my employees Below is the policy and job site information. Insurance Company Name: (t7�� ,,\\J� 1C " (� [� Policy#or Self-ins.Lic.#: b C 2.\)8% OS S ,V t Expiration Date: `k O'2-0 -- ! l �/J f� 7 / Job Site Address: / LA B e-;.J';L,�) �(J) City/StatetZip: /v u'��1,`t i U s ik V L b C,7 it 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 provided above is true and correc Signature: _ Date: ( C 20 Phone#::-C.i? C L 0 (V 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#: tri Ktnomo-ireeveadiO Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Individual OLIVERKELLY Registration: 128957 8 IVERINE Expiration: 06/13/2021 YARMOUTHPORT,MA 02675 Update Address and Return Card. SCA 1 0 20M-05/1177 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: Reciistradon ExoiratioR Office of Consumer Affairs and Business Regulation 128957 O6/13/2021 1000 Washington Street -Suite 710 OLIVER KELLY __= Boston,MA 02118 ! "n OLIVER M.KELLY.. 8 RHINE RD. YARMOUTHPORT,MA`02875 Undersecretary Not valid without signature Commonwealth of Massachusetts -1171 Division of Professional Licensure Board of Building Regulations and Standards Construction Supervisor Specialty CSSL-099167 Expires:09/28/2021 OLIVER M KELLY 8 RHINE ROAD111111 YARMOUTH PORT MA 02675 i Commissioner Ajz..A4.)1•14.4-0,-1---- Ac o CERTIFICATE OF LIABILITY INSURANCE DATE(MMID°"'"Y) �••�� 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 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 CONTACTO Linda Sullivan DOWLING&O'NEIL INSURANCE AGENCY mic,No.an: (508)775-1620 FAX (AIt. E-MAIL ADDREss: Isullivan@doins.com 973 IYANNOUGH RD INSURER(S)AFFORDING COVERAGE NAIC r HYANNIS MA 02601 INSURER A: ACE AMERICAN INSURANCE CO 22667 INSURED INSURER B KELLY ROOFING INC INSURER C: INSURER D 8 RHINE RD INSURERE: 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.UMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE RASO 1NVD POLICY NUMBER (MMIDDYYYY) (MWDD/YYYY) MATS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY JECOT- 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 LIAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X STATUTE OTH- ER AND EMPLOYERS'LIABILITY Y/N ANYPROPRIETORIPARTNER/EXECUTIVE E.I.EACH ACCIDENT $ 500,000 A OFFICER/MEMBEREXCLUDED? N/A 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 EL DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Ranarks 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-compensationrnvestigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POUCIES 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 C. Yarmouthport MA 02675 ' Daniel M.Crr vley,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