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HomeMy WebLinkAboutBLD-23-005491 R DE C ::: I V xD Office Use Onlo -7APR � l•�{. t c 2023G Z+\ . y: Amount •!' aArT'M s "1' BUILDING<r..,,t.3E % By DARTMENT Permit expires 180 days from ,;; issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 � CONSTRUCTION ADDRESS: 5 i ` k./ SO. -l.42 ASSESSOR'S INFORMATION: Map: 67 Parcel: at/ OWNER: 1\09--e"1.S CO r0 st•E S(i CA.P7.--D.06_ LEAb i SD. k440.. OJ,)-rvk K -A a bby NAME PRESENT ADDRESS , TEL. # 4!3 Gig" 5556 CONTRACTOR: 'J�% -"1 -'UU( <a \%IQ(.. �V- O imAkianikpoti_7 !AA 02.I0i c NAME MAILING ADDRESS 1 TEL.# g Sf)G laJR m esidential ❑Comercial Est.Cost of Construction$ (O pcio Home Improvement Contractor Lic.# l2'301 J, Construction Supervisor Lic.#INC1 i 67 Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I1 am the sole proprietor I have Worker's Compensation Insurance Insurance Company Name: 4Co auCAN Worker's Comp.Policy#6S(:)2l)Gfi1.1:") S$OcI27 WORK TO BE PERFORMED Tent II Duration (Fire Retardant Certificate attached?) Wood Stove El Siding: #//of Squares Replacement windows:# Replacement doors: # Roofing:i #of Squares (I )Remove existing*(max.2 layers) Insulation El I ] Old Kings Highway/Historic Dist. a)Replacing like for like Pool fencing I I f .� *The debris will be disposed of at: '�Q-+4-0-) t'�4 3S—Lx 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 denial or revocation of my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature.. � ) , k, D Date: 0 / Gf 7 23 Owners Signature(or attachment) // / Date: ,A Approved By: GG" Date: 7 Building Official( esi ) EMAIL ADDRE S: Zoning District: Historical District: Yes No Flood Plain Zone: Yes :- No Water Resource Protection District: Within 100 ft.of Wetlands: Yes No 1 Yes - No Department of Industrial Accidents . Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/bra • Workers' Compensation Insurance Affidavit:Bulders/Contractors/EIectricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): LL3-t 200-E(t3 G 'iVx„- . Address: vJc. Q_QAZ City/State/Zip: AQ-MCr,�': -C f�, O 1 Phone#: 5o 501 4(O Aree u an employer? Check the appropriate bog: Type of project(required): 1.E1 I am a employer with t • 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attarhed sheet. 7. El Remodeling ship and have no employees These subcontractors have 8. []Demolition working for me in any capacity. . employees and have workers' 9. ❑Building addition [Ni)workers' comp.insurance comp.unSurance.t _ required.] 5. D We are a corporation and its 10.❑Electrical epa±rs or additions 3. officers have exercised their❑ I am a homeowner doing allwork -11.0 P mg repairs or arlrlitjorts myself.{No workers'comp- - right of exemption per MGL . 12. Roofiepaus insurance required_]t c. 152,§l(4),and we have no employees, {No workers' 13.0 Other comp.insurance required.] . *Any applicant that checks bore#1 must also fill out the section below showing their workers'compensation policy-information. s f Homeowners who submit this affidavit indicating they are doing all wade and then hire-outside contractors must submit a new affidavit indicating such. tConhactors that check this box must attached an additional c ei showing the name of the sub-contractors and dot'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 Zr providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Akz C.Juv Policy#or Self ins_Lic_#: 0e:746 k'k.C.)g6g CPI 2-2__ Expiration Date: S' L O - 20.23 Job Site Aririress / `r►'41,/U tDIZZ, fecagu City/SiatelZip: 5 j /4,/2/I r ` 1j1j y Attarh 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 ran lead to the imposition of rrirninal 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 maybe forwarded to the Office of Investigations-of the DIA for insurance coverage ve*i won I do hereby certify- the pains and penalties of perjury that the information pr-oviden above is true and corr 1 Date: _ 2/1 y72o2 Phone#: 5- LW Official use only. Do not write in this area,to be completed by city or town offzciaI. • City or Town: - Permit/Lieense# Issuing Authority(circle one): • 1.Board of Health 2.Building Department 3.Cityfl'own 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. Kellyroofing@icloud.com December 12, 2022 Proposal submitted to Ms. Noreen Couture of 54 Capt. Dore Road South Yarmouth MA. We propose to supply all materials and labor required to remove and replace the existing Double Layered Asphalt Roof at the Address Above. Protect all walls, Windows, shrubs, plants etc. during roof strip. All debris to be removed to town transfer. 8"Aluminum Drip Edge to be installed on all eaves. 5" On All Rakes. All Roof Decking to be Secured. Ice and Water damage protection membrane to be installed on first Six feet of all Eaves and In All Valley Areas. Remainder of roof deck to be covered with synthetic underlayment. Install limited lifetime warranty architect style Shingles, color to be specified, All shingles to be storm nailed (6) We generally use Certainteed products, this proposal is based on their Standard Landmark Limited Lifetime Warranty Shingle. Using all Certainteed Starter and Ridge Shingle Products To Maximize Available Warranties. Replace plumbing vent pipe boots with new. Repair/Replace All Flashings As Necessary. Install Certainteed Filtered Ridge Vent with hand nailed caps. Complete Clean up off all areas including all gutters and all nails after project complete. At a total cost of$10,600 Proposal Submitted by: Oliver.Kelly Proposal accepted by: Q (,(�i Date. j_ /41 /2022 Best Contact Phone : ( 6 61_ j>SS e2 This proposal is valid for 45 days from date above, please call to verify thereafter. Commonwealth or Massachusetts Division of Professional Licensure Board of Building Regulations and Standards ConstructiSipeiVisor Specialty CSSL-099167 Expires: 09/28/2023 OLIVER M KELLY 8 RHINE ROAD +>` YARMOUTH PORT MA 02675 0 n ram! - ... Commissioner :ewe A. t7417c tta. • F riw G'e Geo G(fC/L' / ��GG.�11"L(/C/f7CCr1P. f1 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: 06/13/2023 8 RHINE RD • YARMOUTHPORT, MA 02675 .. Update Address and Return Card. 1CA 1 0 20M-05/17 Office of Cao�Ss2Rne[Aff vs&Eiusiness lfeg 16tion 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 06/13/2023 1000 Washington Street -Suite 716 OLIVER KELLY Boston,MA 02118 OLIVER M.KELLY S RHINE RD. YARMOUTHPORT,MA 02675 Not valid without signet re Undersecretary AC ® DATE(MM/DD/YYYY) C 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: Linda Sullivan DOWLING & O'NEIL INSURANCE AGENCY PHONE No.Ext): (508)775-1620 (A/C,No): E-MAIL ADDRESS: isumvanla2d01ns.Com 973 IYANNOUGH RD INSURER(S)AFFORDING COVERAGE NAIC# HYANNIS MA 026C1 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: 775630 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! 'ADDL SUBR POLICY EFF I POLICY EXP TYPE OF INSURANCE LTR INSD WVD POLICY NUMBER JMM/DD/YYYY) IMM/DD/YYYYI LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCEDAMAGE $ CLAIMS-MADE I I OCCUR PREMISESO(Ea occ�ence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO JECT ,II LOC PRODUCTS-COMP/OP AGG $ OTHER, $ AUTOMOBILE LIABILITY COaMBIacciNEDdentINGLE LIMIT $ (E ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per accident) $ _ NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per accident) $ UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY X STATUTE ER Y/N ANYPROPRIETOR/PARTNER/EXECUTIVE E.L EACH ACCIDENT $ 500,000 A OFFICER/MEMBER EXCLUDED? N/A NIA N/A 6S62UB8H08583922 05/10/2022 05/10/2023 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE! $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below I E.L DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarts 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 an 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 Truro ACCORDANCE WITH THE POLICY PROVISIONS. 24 Town Hall Road AUTHORIZED REPRESENTATIVE fl LU Truro MA 026E-6 Daniel M.Cr y,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 26(2014/01) The ACORD name and logo are registered marks of ACORD .! ...."; • .1....-mmr)vA.. . 14 I, 74•1'-„,./'..4-'',Z,,1,-4 7 I:"--. .-• YT!„,11FiAt_i ‘-:.',1,i 3TA01 !"rf`;I:th) •T1uotiiii1'51Z-6ii-1 f 1.,10q.i 0": t "'..-."'',..„40,0. .-.."..-it-A-:-.1.1:.' : . -7 :.. -.7..eel-S7 1 -.77T--fik. ...= ..7/7-.. C.-7.7:4;37::-;"7i-e-i-iTTL.'!"."...1-14-11'5".--.".-7., •-tif-71----1 :e.7:$0:' 1---•'•• ?..!•,.t. 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