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Home My WebLink About bld-20-004642 -„IA.:: p Permi# ..'y C ��w _ - 1Amount CD _ 1c4 � j $ 4a. v,s,,i4 Permit expires 180 days from jissue date RECEIVED ' : EXPRESS BUILDING PERMIT APPLIC T T- -----Y---- TOWN OF YARMOUTH -_ i Yarmouth Building Department i t ,J 4 ` 1146 Route 28 �3 `- ---____..____._.. South Yarmouth, MA 02664 Bv T (508) 398-2231 Ext. 1261 • CONSTRUCTION ADDRESS: b COL So . '4411'Ll0.0 l ASSESSOR'S INFORMATION: Map: Parcel: owNER: g oL, LjAz S. 4Ap_mt3,ink AA 0abb( NAME 1 PRESENT ADDRESS a coNT AcroR: W4 v. +AO Cr \ - S at/I aJL vc 0 urti MA E i b2 NAME MAILING ADDRESS ' 1 h1.,.# ✓ S v1 c- ' t-t SJ e Residential 0 Commercial Est.Cost of Construction Home Improvement Contractor Lie.# I.Q. 9 i S-7 Construction Supervisor Lic.# C' lb,I Workman's Compensation Insurance: (check one) 0 I am the homeowner Cl I am the sole proprietor 1. I have Worker's Compensation Insurance Insurance Company Name:4C 4frtrJc4IJ Worker's Comp.Policy# 21)e qu $g 0g 1c WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares f Replacement windows:# Replacement doors: # Roofing: #of Squares 64 ( ///)Remove existing' (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing q Z, r., *The debris will be disposed of at 4D-1V 1 tiAsVA- Q 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 'on of my,license and fo 'on under M.G.L.Ch.268,Section 1. Applicant's Signanue _\ . Date: 2 14 120 2 Owners Signature(or attachment) . Date: 2 2J ) Approved By: ✓ Date: f -. q iqe Building ' ( i ee) EMAIL S: 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 ►F_� !/ Department of Industrial Accidents v 1 Congress Street,Suite 100 j— e Boston,MA 02114-201 www.mass.gov/dia Vi orkers'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.L.K P-..1010X.t�V Address:Ct) Ne. City/State/Zip W (52-tric Phone#:5 1 Ltb l o Are you an employer?Check the appropriate box: � Type of project(required): 1.1�'am a employer with ` employees(full and/or part-time).* 7. ❑New construction 2.0 lam a sole proprietor or partnership and have no employees working for me in 8. 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.]' 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 general contractor and I have hired the sub-contractors listed on the attached sheet. 13.Doof 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 iding workers'compensation insurance for my employee& Below is the policy and job site information. Insurance Company Name: C. ' Policy#or Self-ins.Lic.#: b 2_0 1-1O' )( ) C)tei Expiration Date: `k d'-ZO Job Site Address:46 6\D-0k- 4.4z, City/State/Zipb. i& iik 0�-b�0t( Attach a copy of the workers'compensation policy Ieclaration page(showing the policy number nd expirati n 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: 2 ( 2� 220 Phone#: .J SOCk 1bL 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#: • Y-Z Kt-nome-i-moeadi6>Z.AaJd-ardea-g/4- 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✓/1177 ril.Yi/.6.mv/li va.4i •fliliavl/[Yllhir//-i Office of Consumer Affairs 8: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; x X 8 RHINE RD. gioo.d lt.'&i i' 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:09/2812021 OLIVER M KELLY 8 RHINE ROAD YARMOUTH PORT MA 02675 . • a . Commissioner itju;d'r'/' AW DD CERTIFICATE OF LIABILITY INSURANCE DATE(PaWDOIYYT 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 poiicy(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). PR00UCER NAM:AC Linda Sullivan DOWLING&O'NEIL INSURANCE AGENCY PHONE .Exit: (508)775-1620 (FAAC,Nor. E-MAIL A D : Isul ivan@doins.com 973 IYANNOUGH RD I AFFORDING COVERAGE NAIL s HYANNIS MA 02601 IIISURERA: ACE AMERICAN INSURANCE CO 22667 INSURED INSURER B: KELLY ROOFING INC INSURER C: INSURER D 8 RHINE RD INSURER E: YARMOUTHPORT MA 02675 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 POUCIES.UBR LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. MISRLIR TYPE OF INSURANCE DfyRtm POUC NUMBER 11N POODN ) IMWDONYYYL UNITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE CLAIMS-MADE OCCUR PRMISS TO RENTEDPREEMISES(Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&Aov*INJURY $ GENT_AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ POLICY JERC n LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE UASI TY COMBNNED SINGLE LIMIT $ (a accident) ANY AUTO BODILY INJURY(Pe person) $ — ALL OWNED `—SCHEDULEDAUTOS AUTOS N/A BODILY INJURY(Per accident) $ NON-OPROPERTY DAMAGE HIRED AUTOS AUTOS RIF�N (Per ac iderd) $ S UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS UABCLAIMS-MADE N/A AGGREGATE $ OED RETENTIONS $ WORKERS COMPENSATION OTH AND EMPLOYERS'LIABILITY X STATUTE I ER YIN ANYPROPETORlP�HVE RI EL EACH ACCIDENT S 500,000 A OFFICER/MEMBER cr ion)? n WA WA 6S62UB8H08580919 05/10/2019 05/10/2020 (Mandatory in NH) EL DISEASE-EA EMPLOYEE $ 500,000 6 yes describe under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 181,Addlfaratl Remarks Sdmedule,may be attached N 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 daims 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 coverbge can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.govfivid/workers-compensafionfinvestigationa 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 AUTHORIZED REPRESENTATIVE Yarmouthport MA 02675 Daniel M.Croiky,CPCU,Vice President—Residual Market—WCRIBMA Ci 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD