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Home My WebLink AboutBld-20-003614 •Y - I:.ce Use Only r g 4-irei .1 i - nwftun a Amount s�$ iPennit expires 180 days from !tissue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 *901 South Yarmouth,MA 02664 id oyjD / (508)398-2231 Ext. 1261 CONSTRUCTION ADDRESS: ( e_ \,5L,A,„),A QszAL qx,DG \tk 1,is DtEk f- ASSESSOR'S INFORMATION: Map: 4SSOC - Parcel:OWNER: A l.G‘(0-itC 0 .4).4) J s—rot... I 4,1,12,m.G.0 ANTE PRESENT� ADDRESS TEL. if -0047 35 CONTRACTOR: I W#1 c i ttrk'i CT l `c.7 l)iA 1 tur IR 4N i, r :.av;U l:r•1-!, :/;+1' c l rj_'�� NAME MAILING ADDRESS TEL# 6 0 4 4240 2 4 0 EI Residential 0 Commercial Est Cost of Construction$ t• 0, urn-) Cf Home Improvement Contractor Lie.# i 1,2 A 9 5-7 Construction Supervisor Lie.# C)-; . I h I Workman's Compensation Insurance: (check one) /� ` 0 I am the homeowner 0 I am the sole proprietor tic have Worker's Compensation Insurance ACF ' 21J6 __5q' ' ` RInsurance Company Name- M�!1 '� Worker's Comp.Policy? � .-t v 5t� �`� d WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares r� Replacement`` windows:# Replacement doors: # Roofing: #of Squares gS ( d )Remove existing*(max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will'be disposed of at 14 ti 1 ;' yvS 1L 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 - n of myjlicense and fo 1 son under M.G.L.Ch.268,Section 1. Applicant's Si... Date: I Z 26 I L g •� Owners Signature(or attachment) Date: 1 Z 1 tQ, Approved By: Q_ st-r0 M.�• h A ved `12 Date: h d.) 'ii Building Official(or designee) EMAIL ADDRESS: Zoning District Historical District 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District Within 100 fi.of Wetlands: 0 Yes 0 No 0 Yes 0 No KELLY ROOFING PH. 508 509 4640 8 Rhine Road MA C.S.L. #099167 Yarmouthport MA H.I.C.R. # 128957 MA 02675 December 5 '2019 Proposal submitted to Management of 300 Buck Island Road West Yarmouth MA. We propose to supply all materials and labor required to remove and replace the existing double layered asphalt roofs on Building 14 Units D, E & F 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 Certainteed Landmark Architect style Shingles, color to be Birchwood, Light Gray All shingles to be storm nailed (6) Replace plumbing vent pipe boots with new. Repair/Replace all flashings as necessary. Install Certainteed filtered Shingle Vent ridge vent with hand nailed caps. Complete Clean up off all areas including all gutters and all nails after project complete At a total cost of$10,050 Payment Schedule; Balance upon Completion Proposal Submitted by: Oliver Kelly Proposal accepted by: Date. / /2019 This proposal is valid for 45 days from date above, please call to verify thereafter. The Commonwealth of Massachusetts t traw_ 4# Department of Industrial Accidents • tr_V � e =;1.11= � 1 Congress Street,Suite 100 13I,4 [ Boston,MA 02114-2017 '��-i < wow mass gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information ii� l� Please Print Legibly Name (Business/Ors ization/Individual):U�r(.t, P.-Oar _ _ n ti3V Address: . N e. . CitylState/Zip: � 4 (Rijn Phone#:5 t'tb4.0 Are you an employer?Check the(appropriate box: Type of project(required): 1.' t am a employer with ` employees(full and/or part-time)." 7. ❑New construction 2.0 I am a sok proprietor or partnership and have no employees working forme in 8. 0 Remodeling any capacity.[No workers'comp.insurance required.] 3.0 i am a homeowner doing all work myself.[No workers'carp.insurance required.]f 9. ❑Demolition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 0 Building addition 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 generai contractor and I have hired the sub-contractors listed on the attached sheet 13. 6of 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 c. 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. *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. [(the subcontractors have employees,they must provide their workers'comp.policy number. I am an employer that is pr iding workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: e/, ken (j (� Policy#or Self-ins.Lic.#: o��•8 b_ ,0 j7 5 Q-i 0 PI Expiration Date:c� `k 0 -Z0 Job Site Address:L" )' of \ 1ts 1 b City/State/Zip: ,�,°MSX� 'ilk 02L513 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. l do here ader the pains , , ,hies of perjury that the information provided above is true and come 1 Signatur t • i� Date: 12-. i 24o Phone#: E 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): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: �i F�,nma 2 emu i o% aeh�- 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 0 20M-05/17 oiiirral/>/:142 64211 /4,/% 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: Realstraton_` 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, ' 8 RHINE RD_ • YARMOUTHPORT,MA 02675 Undersecretary Not valid without signature L 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 ROADaft YARMOUTH PORT MA 02675 Commissioner xii" `" 4 Aco CERTIFICATE OF LIABILITY INSURANCE DATE`"""OIWYYy) 07/02J2019 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(les)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 raw: Linda Sullivan DOWLING&O'NEIL INSURANCE AGENCY PHONE IA/cN . ,. (508)775-1620 FAX ,Na,: ADNORES& Isullivan@doins.com 973 IYANNOUGH RD INSURER(S)AFFORDING COVERAGE NAIL a 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.UMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE wve POUCYNIJMBER RAWDD1YYYYYYI (WAIDD/ifYYYY flj LIMITS COMMERCIAL GEPHERAL LIABM mr EACH OCCURRENCE S O CLAIMS-MADEn OCCUR PRMISESlRENTED PRERNISES IEa oo:xxreixet $ MED EXP(Any one person) S N/A PERSONAL 8 ADV INJURY S GE RI AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE S POLICY n PET- El LOC PRODUCTS-COMP/OP AGG $ OTHER: S AUTOMOBILE LIABILITY COPABINEDDSINGLE LBAIT s (Ea acciden _ANY AUTO BODILY INJURY(Per person) S ALL OWED SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Peraccidenf) $ AUTOS NON-OYNNED PROPERTY DAMAGE HIRED AUTOS i AUTOS (Per S UMBRELLA LIAR OCCUR EACH OCCURRENCE S EXCESS LIMB CLAIMS-MADE N/A AGGREGATE S DED _I RETENTIONS WORKERS COMPENSATION PER OTW AND EMPLOYERS'LIABILITY Y/N X STATUTE _ ER ANYPROPRIETORIPARTNER/EXECUTIVE EL EACH ACCIDENT $ 500,000 A oFFICERAeEMesRExrLuoso? WA WA WA 6S62UB8H08580919 05/10/2019 05/10/2020 (Man datory M EL DISEASE-EA EMPLOYEES 500,000 yes, DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEEHICLES(ACORD 101,Additional Remarks Schedule,may be attached M more apace 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 dais s for benefits to employees in states other than Massachusetts lithe 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_govnwd/wodcers-compensationfinvestigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DEUVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. The Barnstable Insurance Company 108 Route 6A AUTHORIZED REPRESENTATIVE Yarmouthport MA 02675 —. C Daniei M.CrcWiey,CPCU,Vice President—Residual Market—WCRIBMA ®1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014A1) The ACORD name and logo are registered marks of ACORD