Loading...
HomeMy WebLinkAboutBld-20-003523 Y Office Use Only • F' „�„ cs rAmomt 6, � t'1Permit expires 180 days from ?t issue date EXPRESS BUILDING P ERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 stcSouth Yarmouth, MA 02664 w (508) 398-2231 Ext. 1261 . IT/CONSTRUCTION ADDRESS: 1 pii..)i. C"`1?©J c al S.. q q 0 g..) ASSESSOR'S INFORMATION: Map: Parcel: • OWNER V-,TA "`4lv�si-Ti /r-)�, 1An 02 n��t l.�l t;LSC�I �"a1 2 IS 0 NAME PRESENT ADDRESS , TEL. # II e6�6C1 3349 s r CONTRACTOR: �i4 (i7Ji uk)C5- tom.- Lt i&: tZAN ` `A;P_,i;0 y,-tA ;I VA v 1 b 7S NAME MALE DIG lG ADDRESS ' TEL s 2 Residential 0 Commercial Est Cost of Construction$3 AA 5iv t f� f r� �, ) Home Improvement Contractor Lie.# 2IS 5 , Construction Supervisor Lic.# L'.J i b I Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor dchave Worker's Compensation Insurance Insurance Company Name:4(7',F. 4frtr t Worker's Comp.Policy?1 i %U 7 f4 i.; E ci S l WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares 10 ( d )Remove existing (max.2 layers) Insulation Old Kings Highway/M.:torte Dist. ( )Replacing like for like Pool fencing *The debris will'be disposed of at i /Tx'—s'V +J j ;'A.,—-i�1` 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 belieL I understand that any false answer(s) will be just cause for on of my,license and fo on under MG.L.Ch.268,Section I. Applicant's Signanr Date: 11 t ( Owners Signature(or attachment) Date: Approved By: ,--��e Date: / ' ! 7 Buildinv cial ignee) EMAIL ADC "W I.— 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 P. = ��el Department of Industrial Accidents e ,i j�1. ; 1 Congress Street,Suite 100 _3:-. * Boston,MA 02114-2017 ., it, 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/Org ization/Individtral): k��K k� Address: ] 11) . ty p�ge rt4 '- 4l t (1)J5lc Phone#: 5 21 41040 Gi /State/Zi Are you an employer?Check the appropriate box: Type of project(required):( 1.6am a employer with ` employees(full and/or part-time).* 7. ❑New construction 2.❑1 am a sole proprietor or partnership and have no employees working for me in 8. El Remodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]f 9. ❑Demolition 4.0 lam a homeowner and will be hiring contractors to conduct all work on my property. I will 10[l 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.[ roof 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.El 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. I am an employer that is pr iding workers'compensation insurance for my employee& Below is the policy and job site information. Insurance Company Name: [CI,�Z\)4e ACA4 !� a` _0 Policy#or Self-ins.Lic.#: b( ' (U 5 1 0.� Expiration Date:5 `\ Job Site Address:11 .1)i ry f, ( AS-.A. City/State/Zip: t .M 'ilk O2 6 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 hereb ( rti to pains and penalties of perjury that the information provided above is true and correc Signature: Date: I� 1 nD '7 Phone#: &—j l L 1Q 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#: tc-Z K -riomo-/?,ebteadi6,4Aa,),5er,0,46d-e/Z.), 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 v 20/ (i!.M-05//1177 .J L' 'I////%/Y///#'Z( A/..1474M60!//4,514 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: gegjagatigg Exoiration Office of Consumer Affairs and Business Regulation 1289 67:;;;°== _06/13/2021 1000 Washington Street -Suite 710 OLIVER KELLY`,' _=;:' -,; Boston,MA 02118 OLIVER M.KELLY i • 8 RHINE RD. Ka.t fit" 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 ROAD1101 YARMOUTH PORT MA 02675 ir } { Commissioner ( Aco CERTIFICATE OF LIABILITY INSURANCE DATE(MWODFYYYY) `-r 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 poticy(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 NAB Linda Sullivan DOVVLING&O'NEIL INSURANCE AGENCY ,�Exn, (508)775-1620 FAX X`,NOI: ADDRESS: Isuilivan@doins.com 973 IYANNOUGH RD INSURER(S)AFFORDING COVERAGE NM* 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. NOWATHSTANDING 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 TYPEOr INSURANCE �WVD POLICY NUMBER i D/MY1 I)JDRYYYYYY) UINTS COIIIMERCIALGENERALLIABIUTY EACH OCCURRENCE S O CUUMSMADE El OCCUR DAMAGE PREMISES(RENTED tEe occvrrierhoe) S MED EXP(Any oneperson) S N/A PERSONALS ADV INJURY S GENE AGGREGATE UNIT APPLIES PER GENERAL AGGREGATE S POLICY n, T n WC ,PRODUCTS-COMP/OP AGO OTHER: AUTOMOBILE LIABILITY coactidE°mom taxi' S (EaANY AUTO BODILY INJURY(Per person) — S ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per accident) S DAMAGE _ HIRED AUTOS AUTOS (PROP accidenti er _ S UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS UAB _ CLAIMS-MADE N/A AGGREGATE S DED I RETENTION S S WORICERS COMPENSATION X PERETUTE OTH- AND EMPLOYERS LIABILITY Y/N A OA" ° EXCLt � WA WA WA 6S62UB8H08580919 05/10/2019 05/10/2020 VE EL EACH ACCIDENT S 500,000 (Mandatory M ) EL DISEASE-EA EMPLOYEE,S SOO,000 Ddesabe under eSeAllinoN Of OPERATIONS below EL DISEASE-POLICY LIMIT S 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remsrka 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 day by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/Iwd/workers-compensatiorYmvestigations/. 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 POLICYPROViSIONS The Bamstabie Insurance Company 108 Route 6A AUTHORQ@REPRESENTATIVE Yarmouthport MA 02675 ( 1 Daniel M.CroQey,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 KELLY ROOFING PH. 508 509 4640 8 Rhine Road MA C.S.L. #099167 Yarmouthport MA H.I.C.R.# 128957 MA 02675 December 9, 2019 Proposal submitted to Rita Yannetti of 175 Pine Grove Road, South Yarmouth 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. 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 Architect style Shingles, color to be specified, C1,Cc iic,e-r,,(.L- All shingles to be storm nailed (6)We Generally Use Certainteed Products with All Accessories to maximize available warranties.This quote is Based on The Regular"Architect"Style Landmark Series Shingle Replace plumbing vent pipe boots with new. Repair/Replace all flashings as necessary. Install Shingle Vent II 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$3,950 Payment Schedule; Balance upon Completion Proposal Submitted by: Oliver Kelly If Acceptable please sign an urn a copy to the address above. Proposal accepted b / ' ' Date. /a / /v 12019 , ./C vitia,:ttc This proposal is valid for 5 days fro ate above, please . call to verify thereafter. Best Contact Info: //_e4,"( iyn.4`C _ / �� 4-u) C ,) pD,4, 3 7 Cott/n:4y e e 2eet/ ;��r l% /5 L% IireP /7 — gif - 3z/ 3 e /7- c> 9 0Ii