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Home My WebLink Aboutbld-20-003402 •Y:4 Office Use Only k> o N y Amount ! ,L== 6 E .Permit expires 180 days from !'issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH _ pr- ' i ,;. Yarmouth Building Department �p..- 1146 Route 28 South Yarmouth,MA 02664 _,. za(7 ( 08) 398-2231 Ext. 1261 J., ,.. �CONSTRUCTT ON ADDRESS: iej?!f- � �� °�G (? ) V ASSESSOR'S INFORMATION: Map: Parcel: • OWNER ')\cl,yA El Mi k r''V't 02-6 NAME PRESENT ADDRESS TEL. I CONTRACTOR: :A: n � C�.�J*- G"' tom•-- S lti..il l ; t:.-CA .q 4:-+v',0 l�.r-►.t Ali J.� �,.!� ;_� V NAME MAILING ADDRESS t TEL# _r'f r, !_.-, esidentiai • mmercial Est Cost of Construction$ al-100 Home Improvement Contractor Lie.# f,� 15� ' Construction Supervisor Lic.# OCI6) l b.7 Workman's Compensation Insurance: (check one) ` D I am the homeowner 0 I am the sole proprietor II-have Worker's Compensation Insurance Insurance Company Name:4CE.. Avl >I .4-Al$ Worker's Comp.Policy? U -1 q u'S J R I 9 WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares '\ ( f)Remove existing'(max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at_ qx).„,....,,...„ +( ;' iC t Location of Facility I declare under penalties of perjury that the statements herein contained are true and correct to the best of my lmowledse and belief. I understand that any false answer(s) will be just cause for on of my license and on under M.G.L.Ch.268,Section 1. Applicant's Si . Date: 12 ( 1 l 1 11 Z074 :Date: u1 N'n )rj Building Official(or designee) EMAIL ADDRESS: Zoning District Historical District 0 Yes 0 No Flood Plain Zone: ❑ Yes Cl No Water Resource Protection District Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No _ x _ The Commonwealth of Massachusetts t -' ft Department of Industrial Accidents =ri = 1 Congress Street,Suite 100 _ l,;E= Boston,MA 02114-2017 >r www.mass.gov/dia mas&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/Individual):��L.1.S-k if t'JfV Address: 1V 3lc Ci /State/ F��S Phone#: Sc-j1 LUC,4.0 tY ZiP� �� Are you an employer?Check the appropriate box: Type of project(required): J I 1. am a employer with ` employees(full 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 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 El 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 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 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. 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 ding workers'compensation insurance for my employee& Below is the policy and job site information. Insurance Company Name: �',,t-. ``2.\C Policy#or Self-ins.Lic.#: C7Z08 b t1O V F; Ll V tel Expiration Date:cJ 'k O" 2.0 Job Site Address: 2C11 let35 ) City/State/Zip:L k(t td4 ® -73 Attach a copyof the workers'compensation policydeclaration page(showingthe policynumber and exPiraaidate). 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 here :der the arras , 'es of perjury that the information provided above is true and correc Signatures t I , Date: 1'1 ( 1 11 i - Phone#: 6 1) 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#: ,rT ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MMIOOIYYYV) 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 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: It the certificate holder Is an ADDITIONAL INSURED,the poiicy(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 mule Linda Sullivan DOWLING&O'NEIL INSURANCE AGENCY rmic., EXU: (508)775-1620 FAc,No): R ems: Isuilivan@doins.com 973 IYANNOUGH RD isuacas AFFORDING COVERAGE NAIC# HYANNIS MA 02601 INSURER A: ACE AMERICAN INSURANCE CO 22667 INSURED INSURER B: KELLY ROOFING INC INSURER C: INSURER 0: 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 POUCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OFRISURAN POUCY NUMBER ( INOWYYTYL HAWDEVYTYYI LIMBS COMMERCIAL GENERAL UABLITY EACH OCCURRENCE $ CLAIMS-MADE n OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) MED EXP(My one person) ,$ N/A PERSONAL&ADV INJURY $ GENT.AGGREGATE LIMIT APPUEES PER GENERAL AGGREGATE _$ POLICY JECTT El LOC PRODUCTS-COMP/OP AGG $ OTHER _ S AUTOMOBILE LIABIUTY COMBINED T $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ All OWNED -SCHEDULED, AUTOS AUTOS NIA BODILY INJURY(PeracciderP) $ VVNED HIRED AUTOS ` Amos Per as ttI $ _ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE N/A AGGREGATE S 0ED I RETENTIONS $ WORKERS COMPENSATION X PTATt1iE OT AND EMPLOYERS'LIABILITY Y/NER ANYPROPRIETORPARTNEwEXECunvE EL EACH ACCIDENT $ 500,000 A oFFICEwMEMeERExCLUDED? n WA WA 6562UB8H08580919 05/10/2019 05/10/2020 I�yea,atory n h)er EL DISEASE-EA EMPLOYEE`S 500,000 desaDESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached I 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 claims 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 Wow mass.govnwd/workers-compensauonfmvestigations/. 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 AUTH ORRrDREPRESENTATIVE Yarmouthport MA 02675 `_ t I Daniel M.Crot'vy,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 Q/eAarlf - Cif iz,Je'/!J..i- 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 20/4-05/17 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 8 RHINE RD. �(.a.+t'� r s �.� 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:0912812021 OLIVER M KELLY 8 RHINE ROAD YARMOUTH PORT MA 02675 � k" Commissioner