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Home My WebLink Aboutbld-20-003234 •Y. ,� —� n otfi�euseonly `? ,a,,,ry�(\\4010 0 1Permitif - w„, :dam l' L l)j 2019 I IAmount 5V— 6+ ! i I Permit expires 180 days from G !;issue date u;I (1 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH 13LI)- Z-- 3 (1 Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 C� (508)398-2231 AA.) Ext. 1261 CONSTRUCTION ADDRESS: t ✓ ` C. \I l r- L J r ap.• LIA,e_m_au. -ti ASSESSOR'S INFORMATION: Map: 25 Parcel: S • '' OWNER: \) \t :f k`Uk_ VJ `5<X. l OO(i jPT cr.) 4 0 k S l ' NAME PRESENT ADDRESS TEL R?aONTRACTOR: �m-a+d1 tr tv ir \ cy 1-1 u i rJL I.Z. v '7' NAME MAELMG ADDRESS ` TEL. _., . . ,g_; ��::,{S `.:J`I. J v rt,J e Residential 0 Commercial Est Cost of Construction$ti co J Home Improvement Contractor Lie.# t a r, 9�~? Construction Supervisor Lie_# OS.'6/ I Yi Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor have Worker's Compensation Insurance Insurance Company Name:4C1-1-- �1 ! l Worker's Comp.Policy# %UC--) 0 U' c, t? t"2`?71 l WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares \Q ( 4.()Remove existing'`(max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at 11+14—Aila '. I :.'ASrus 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 f •on under M.G.L.Ch.268,Section I. + / ! , , Applicant's Sign \p. Date: t 1 ( ( + Lv L Owners Signature(or attachment) +�O s Date: 12-- (a - t i Approved By: '' 1 / Date: C 2 G_ Building cial designee) E ADDRESS: Zoning District: Historical District 0 Yes Cl No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District Within 100 ft.of Wetlands: 0Yes 0No 0Yes D. No The Commonwealth of Massachusetts Department of Industrial Accidents • :41 1 Congress Street,Suite 100 _p_ "•0 Boston,MA 02114-2017 s � 0s 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/lndividual):U`r E, Address:54j CilState/Zity p4/ N t11.441 (52t7c Phone#: S °1 Lib k-l0 Are you an employer?Check the appropriate box: Type of project(required): 1.6mn 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.] 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]f 9. El Demolition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Q 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#I 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. 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: ei7; A -\C,I#t Policy#or Self-ins.Lic.#: b0 (02\8 )110;5%O tei Expiration Date:c) `t 0' ZC) Job Site Address: 1 °' City/State/Zip: q,r42fily:11l ilk- Q L660 y 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 hereby certify under the pains and penalties of perjury that the information provided above is true and correc Date: 12 I 6 1ct c �gSignature: � u Phone#: L6c 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#: ACORO CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 09/03/2019 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 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 endorsement(s). PRODUCER CONTACT NAME: Linda Sullivan DOWLING & O'NEIL INSURANCE AGENCY A//C No.Extl: (508)775-1620 FAc,No): ADDRESS: Iullivan®doins.com 973 IYANNOUGH RD INSURER(S)AFFORDING COVERAGE NAIC# HYANNIS MA 02601 INSURER A: ACE AMERICAN INSURANCE CO 22667 INSURED INSURER B KELLY ROOFING INC INSURERC: INSURER D: 8 RHINE RD INSURER E: YARMOUTHPORT MA 02675 INSURERF: COVERAGES CERTIFICATE NUMBER: 443771 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTRINSR WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCEEND S CLAIMS-MADE OCCUR PREMISESO(Ea occu ence) $ MED EXP(Any one person) S N/A PERSONAL 8 ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG S OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S (Ea accident) _ ANY AUTO BODILY INJURY(Per person) t ALL OWNED SCHEDULED AUTOS N/A BODILY INJURY(Per accident) $ _ AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS (Per accident) UMBRELLA LIAB _ OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTIONS �/ S WORKERS COMPENSATION X STATUTE H TUTE ER AND EMPLOYERS'LIABILITY ANYPROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $ 500,000 A OFFICER/MEMBEREXCLUDED? N/A N/A N/A 6S62UB8H08580919 05/10/2019 05/10/2020(Mandatory in NH) E.L.DISEASE EA EMPLOYEE $ 500,000 B yes,describeN under OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTIO N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,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 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 daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.govnwd/workers-compensatioMnvestigations/. 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. David Citino 111 Nantucket Avenue AUTHORIZED REPRESENTATIVE South Yarmouth MA 02664 Daniel M. CroVey, 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 t,d1Z F0/22,120-17,10eCGI/ea-/Aac)J-ade6c3-e/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 Expiration: 06/13/2021 YARMOUTHPORT,MA 02675 Update Address and Return Card. SCA 1 Cr 20M-O5/17 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 OUVER KELLY __'_ Boston,MA 02118 OUVER M.KELLY_ t: .� L"L 8 RHINE RD. garxisf 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 *ft YARMOUTH PORT MA 02675 %lift _ Commissioner A14a.42 ,441-`‘'‘--