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Home My WebLink AboutBld-20-003463 Ysq� Office Use Only ems,.. O y Permit# 0 . :04 y a r t4 --1�. 4' Amount ,�(�� ['Permit expires 180 days from _V E?issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH II, Yarmouth Building Department 1146 Route 28 Cj South Yarmouth, MA 02664 Q 1 (508) 398-2231 Ext. 1261 (6 CONSTRUCTION ADDRESS: /S l.A•r�1 t..) ODD a . t, itvarvvo_tprli ASSESSOR'S INFORMATION: Map: 'So Parcel: 1(� . OWNER: PA J L'ec PO SoiL. 1 0440k..zNAME `� ADDRESS IAA- n20�51 (� TEL. # Sobl il$1 CONTRACTOR: Ikei.4-vl n i7Jrr-tv i G'' \ - P-a i ilia lUA A41AA U l.i?-!.l MA C4 a 7S NAME MAILING ADDRESS ` TEL# c‘ 1 t Residential 0 Commercial Est.Cost of Construction$ AD`cl 01 Home Improvement Contractor Lic.# 1?40 1 i Construction Supervisor Lic.# c'7 ) /h I Workman's Compensation Insurance: (check one) / 0 I am the homeowner 0 I am the sole proprietor s I have Worker's Compensation Insurance Insurance Company Name:4CF 4,,,,>;Y.'tt Worker's Comp.Policy# %Ue '�CY3', 0 R I i WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# .2) Replacement doors: # Roofing: #of Squares 2..?) ( 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 :' r 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 ration of my,license and fo )cution under M.G.L.Ch•268,Section 1. Applicant's Signatur •` Date:n It � 17 f 11 Owners Signature(or attachment) Date: Approved By: `. `Date: 1I'"`)7 . 1 s 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 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No _ The Commonwealth of Massachusetts .• ft Department of Industrial Accidents �'.1 !_ '6 1 Congress Street,Suite 100 l j " Boston,MA 02114-2017 -sue www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PEERMITTING AUTHORITY. Applicant Information Please Print Legibly �� Name(Business/Ong ization/Individual): �� tAY. Address: ICU . City/State/Zip ASS. VIA (DIRS Phone#: kb t-k.0 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.❑I am a sole proprietor or partnership and have no employees working for me in 8. CI Remodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑Demolition 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 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 am 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 employees Below is the policy and job site information. Insurance Company Name: C,t—,. 14-11/4k.C.'N(LkCA--1y .0 Policy#or Self-ins.Lic.#: b. 21)8 b�O U l? Expiration Date:c� `(0"2-0 Site Address: O 'P( O( C) City/State/Zip:Ut40,100111 k 02G75 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 violationpunishable 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 certi under the pains an. . nalties of perjury that the information provided above is true and correc o Signatur C. \ •O Date: 12_ 13 9 Phone#:z� LI b 11 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): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: KELLY ROOFING PH. 508 509 4640 8 Rhine Road MA C.S.L. #099167 Yarmouthport MA H.I.C.R. # 128957 MA 02675 INSURED November 03' 2019 Proposal submitted To Mr. Paul Stanley of 85 Tanglewood Drive West 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 and rakes All Roof Decking Secured Ice and Water damage protection membrane to be installed over first six feet of all eaves, in any valley and around all protrusions Remainder of Roof Deck to be Covered with Synthetic Underlayment Install Certainteed Landmark limited lifetime warranty Architect style Shingles, Using all Certainteed Starters and Cap Shingles to maximize available warranties, (Color to be Specified) All shingles to be storm nailed (6) Repair all flashings as necessary. Install Certainteed Filtered ridge Vent on All Ridges with hand Nailed Caps Replace all Plumbing Vent Pipe Boots With new. Replace Existing Skylights With Velux Units 2 SO6 and 1 MO4 Unit, Including Interior trim and New Exterior Flashing Kits Complete Clean up off all areas including all gutters and all nails after project complete. Obtaining Of Town Permit At a total cost of$13,450 Payment Schedule; Balance upon Completion Proposal Submitted by: Oliver Kelly Proposal accepted by: Date. /I. /7j ? /2019 Be Conta Pho e N b r: AC o® CERTIFICATE OF LIABILITY INSURANCE DATE(MNIDOIYYYY) `.� 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: 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 endorserne PRODUCER CONTACT rime Linda Sullivan D0INLING&O'NEIL INSURANCE AGENCY PHONE is (508)775-1620 Fax (AM. A : Isullivan'a doins.com 973 IYANNOUGH RD INSURER(S)AFFORDING COVERAGE NAM* 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADOL SUER POUCY EFF POUCY EXP LTG TYPE OF INSURANCE INSD WVD POLICY NUMBER IMMIDDJYYYY) (MIWDIYYYY) LIMITS COMMERCIAL GENERALLIABafrY EACH OCCURRENCE $ TO CLAIMSADE OCCUR PROEM SGES(EaEN TED -M ) $ _ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S POLICY JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL AUTOS OWNED L_ AUTOS SCHEDULED N/A BODILY INJURY(Per accident) $ NON-OWNED HIRED AUTOS _ AUTOS PROPERTY accident) $ _ UMBRELLA!JAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE S DED RETENTIONS $ WORKERS COMPENSATION X AND EMPLOYERS'LIABILITY STATUTE ER Y,N ANYPROPRIETORIPARTNERIEXECUTIVE EL EACH ACCIDENT s 500,000 A OFFICERIMEMBEREXCLtxED? WA WA WA 6S62UB8H08580919 05/10/2019 05/10/2020 (Mandatory in NH) EL DISEASE-EA EMPLOYEE $ 500,000 It yes,describe under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remelts ScheMde,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',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.govAwd/worIcers-compensationfinvestigations/. 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 Bamstable Insurance Company 108 Route 6A AUTHORIZED REPRESENTATIVE Yarmouthport MA 02675 `— i Daniel M.Cro4Wyey,CPCU,Vice President—Residual Market—WCRIBMA 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD ti i Kv-nzno-/moeargeAaJci-exoiete4-MX), 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 E Expiration: 06/13/2021 YARMOUTHPORT,MA 02675 Update Address and Return Card. SCA 1 is 20M-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: Eggkaafigg` Expiration Office of Consumer Affairs and Business Regulation 128957=-_;>==_ 06/13/2021 1000 Washington Street -Suite 710 OUVER KELLY Boston,MA 02118 OLIVER M.KELLY 8 RHINE RD. ,,,rt'a.40k 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 • 1116. YARMOUTH PORT MA 02675 t. ; Commissioner / ilir --