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HomeMy WebLinkAboutBLD-23-003738 • c01 f ` - Office Use Only ,�' -,`o= RECEIVED Permit# (0 - '- N' —/1,y Amount -7,j \� rwr, nYcsr,(44,, JAN 0 9 2023 ,..,,'�-,�" Permit expires ISO days from issue date SUIL By: EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Bch 23-(13'73 Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: I ZS 12..1 b.1 e=2C,22 J c - a.7VA_ 4.4...zl .jr_ ASSESSOR'S INFORMATION: i Map: i Parcel: uJ� 1 I ' ,I nWNER. � Vim'` % 6� 4�A•>ZI-LW t Q� �-1 02b15 cCoiS 509 4010 NAME PPRESSNT ADDRESS TEL. # CONTRACTOR:t tW t(� _?-'v3C.- c5 Qk. t. Q . 14-Pcii it 021,1E 50065✓ci GI(040 NAME MAILING ADDRESS TEL.# V Residential ❑Commercial Est.Cost of Construction SIX AC' Home Improvement Contractor Lic.# 12 )q S7 Construction Supervisor Lie.# t,J'-!'1 I b7 Workman's Compensation Insurance: (check one) CI I am the homeown r Cl I am the sole proprietor I have Worker's Compensation Insurance Insurance Company Name: -Mn QtcA- Worker's Comp.Policy n VS ba0 l,�►43. eS?'"V`(2.1 WORK TO BE PERFORMED Tent E Duration (Fire Retardant Certificate attached?) Wood Stove LIII Siding: #of Squares Y 3 Replacement windows:# Replacement doors: # 15 oofing: #of Squares 2� (©)Remove existing*(max.2 layers) Insulation 11 fiOld Kings Highway/Historic Dist. (0)Replacing like for like Pool fencing 'The debris will be disposed of at: 1 �-J '� 1 +`JCL L� Location of Facility !declare under penalties of perjury that the statements he - contained are true and correct to the best of my]stow ledge and belief. I understand that any false answer(s) will be just cause for revocation f my li e d for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signatu . Date: i 6 0 a 23 Owners Signature(or attachme •- Date: . '25 Approved By: i� ill- 4 Date: / 3 Building Official(or designee_ EMAIL ADDRESS: Zoning District: I Historical District: 1 Yes No Flood Plain Zone: _. Yes _ No Water Resource Protection District: Within 100 ft.of Wetlands: _ Yes No 1 Yes No - I I • E cSCS AA1 f f �1: Y f J I --YY d C . 7 ij=Fl • 24 • ;=`' - ;f; "' The Commonwealth of Massachusetts Department of Industrial Accidents 1: Office of Investigations (.� ,r4 F _ .1 Lafayette City Center `\�`" 2 Avenue de Lafayette, Boston,MA 02111-1750 wmv.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information ci Please Print Legibly Name(Business/Organization/Individual): rl4E-(-('- , c--\.N3c,-. Address: $ Ltc- Ciy/State/ZipAQJOS?1 64.-v 02T MA Q.b7� Phone#: Gl Lt(t-L•o Are ou an employer?Check the appropriate box: Type of project(required): 1.101 I am a employer with i 4. 0 I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction listed on the attached sheet. 7. 0 Remodeling 2.El I am a sole proprietor or partner- ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. employees and have workers' 9. 0 Building addition [No workers' comp.insurance comp.insurance.: required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions m self [Noworkers' comp. right of exemption per MGL Y P 12.0 Roof repairs insurance required.]t c. 152,§1(4),and we have no 13.❑Other employees. [No workers' comp.insurance required.] *My 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 providing workers'compensation insurance for mi'employees. Below is the policy and job site information. Insurance Company Name: a, f--itit,EVICA. Policy#or Self-ins.Lic.#: ()%2X)b u Og 0 22 Expiration Date: 5- (0 Lu2 Job Site Address: /2 5 /27 EUCV S R-r:1= City/State/Zip:c5)-V•!A-0t00►"/ /14 02616'/ Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify unde a pains and penalties of perjury that the information provided above is true and corr et. ( ' /fl 'z� Signatur�l L e. �- Date: , =� Phone#: 5DES 60° V i Official use only. Do not write in this area,to be completed by city or town officiaL City or Town: Permit/License# Issuing Authority(check one): 10Board of Health 20 Building Department 30City/Town Clerk 4.0 Electrical Inspector 511Plumbing Inspector 6.1:10ther Contact Person: Phone#: Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards ConstructioolltlO'11spr Specialty C SSL-0991 67 Expires:09/28/2023 OLIVER M KELLY 8 RHINE ROAD k` YARMOUTH PORT MA 02675 :;, !1l4s'',t�l)> .- Commissioner lad fi. t36:7tt . 6/2-4/no-/zepeagi e:// / ' Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Individual Registration: 128957 OLIVER KELLY Expiration: 06113/2023 8 RHINE RD YARMOUTHPORT, MA 02675 Update Address and Return Card. ;CA 1 fi 20fvi-05/17 ./%i Kew/ Cr //' /7iaif Office ofonsumir Affi &�i% es,eg/ t- ion - 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 '28957 06/13/2023 1000 Washington Street -Suite 710 Boston,MA 02118 OLIVER KELLY OLIVER M.KELLY q RHINE RD. Not valid w ithout signat re YARMOUTHPORT,MA 02675 Undersecretary / , ° DATE(MMIDDIYYYY) AM RD CERTIFICATE OF LIABILITY INSURANCE �—;----; 05/17/2022 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: Llnda Sullivan DOWLING & O'NEIL INSURANCE AGENCY IA/C.No.Extl: (508)775-1620 I fA/C,No): E-MAIL ADDRESS: Isulfivan@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: I 8 RHINE RD INSURER E: YARMOUTHPORT MA 02675 INSURERF: COVERAGES CERTIFICATE NUMBER: 775631 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 I 'ADDLISUBR ' POLICY EFF POLICY EXP LTR 1 TYPE OF INSURANCE INSR i WVD POLICY NUMBER 1(MM/DD/YYYY) (MM/DDIYYYYI LIMITS COMMERCIAL GENERAL LIABILITY 1 EACH OCCURRENCE , $ GE TO RENTED I CLAIMS-MADE 1 i OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ I N/A PERSONAL&ADV INJURY $ j GEN'L AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $ POLICY 1—j jE 0 I I LOC PRODUCTS-COMP/OP AGG $ _ OTHER: _ $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per accident) $ I NON-OWNED PROPERTY DAMAGE $ _— HIRED AUTOS ` I AUTOS (Per accident) I $ UMBRELLA LIAB i OCCUR EACH OCCURRENCE I$ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED I RETENTION$ ) $ WORKERS COMPENSATION 1 I X PER OTH- I AND EMPLOYERS'LIABILITY YIN 1, STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE i E.L.EACH ACCIDENT $ 500,000 A OFFICER/MEMBER EXCLUDED? NIA WA N/A . 6S62UB8H08580922 05/10/2022 05/10/2023 (Mandatory in NH) I E L.DISEASE-Fes,EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below I E.L.DISEASE-POLICY LIMIT l$ 500,000 1 I 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 tie 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.gov/Iwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Yarmouth ACCORDANCE WITH THE POLICY PROVISIONS. 534 Winslow Grey Road AUTHORIZED REPRESENTATIVE South Yarmouth MA 02664 —'`-f X Daniel M.Crowley,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