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HomeMy WebLinkAboutBLD-23-005492 i. „„ .r;,�,T .a ti 6 .St�7J ennt Aires 18023 days from ' Z issue date EXPRESS BUILDING PERMIT APPLICATIQ E E 1/ E TOWN OF YARMOUTH -__T D Yarmouth Building Department T BUILDING DEPARTMENT CONSTRUCTION ADDRESS: (� ( t t-LOt,) e' S. tiAwr►j J i !atA 0 2(O6 y ASSESSOR'S INFORMATION: Map: Parcel: OWNER:ZSOt-V) 1 'S12.44 kS 0 A. 27 L ALAI ES�1..5ca01J li% 1445C.6‘ 0 4$ NAME PRESENT ADDRESS TEL. # CONTRACTOR:bLtJ6(Z_ tbowL'1 ' Q t QQ(AD ' t toOii 001S 1 4 O2b7S- / NAME MAILING ADDRESS TEL# 5t fS SO 9 Li b L(D Residential 0 Commercial Est.Cost of Construction$ 23 t 2a J Home Improvement Contractor Lic.# I 2_46q 57 Construction Supervisor Lic.# ORC1(b7 Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole e-pproprietor I have Worker's Compensation Insurancee Insurance Company Name: � 4-1016 Worker's Comp.Policy#643103 S uD SSSCc 2Z WORK TO BE PERFORMED Tent El Duration (Fire Retardant Certificate attached?) Wood Stove El Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares 40 ([)Remove existing*(max.2 layers) Insulation n nOld Kings Highway/Historic Dist. Replacing like for like Pool fencing I t *The debris will be disposed of at: ..A-4 ` l i-Gr+- Location of Facility 1 declare under penalties of perjury that the statements herein contained are true and correct to the best of my knowledge and belief. l understand that any false answer(s) will be just cause for denial revocation of my+1. se and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature � `_��1r� Date: 'f[, '9' Z5 Owners Signature(or attachment) Date: //2--)d.--- Approved By: Date:Building Official(or ) EMAIL ADDR Zoning District: Historical District: . Yes No Flood Plain Zone: t Yes 7 No Water Resource Protection District: Within 100 ft.of Wetlands: Yes No I. Yes _: No • The Commonwealth ofMassachusetts 1r=L Department of Industrial Accidents Fi�I= Office oflnvestigations 600 Washington Street f� "" Boston, MA 02111 • WWw.m Workers' Compensation Tn curance Affidavit:Builders/Contractors/Electricians/Plumbers g A heart Information Please Print Le bI Name(Business/ 'on/Individual): W Q_C/C--WG - Address: O UI-, a City/Sta te/Zip:U_Pg4- PtA02 6 Are appropriate u an employer?Check the ate box: Phone#: ��09 C� C�� Pr 1.Pi I am a employer with_I_ 4. I am a general contractor and I Type of project(required): employees(full and/or part time).* have hired the sub-contractors 6. ❑New construction • listed on the attached sheet 7. 0 Remodeling 2.❑ I am a sole proprietor or par uer- -ship and have no employees These sub-contractors have working for me in any capacity employees and have workers' 8' Demolition • [No workers' comp.insurance comp.insurance_# 9. ❑Building addition 3.❑ required] 5. ❑ We are a corporation and its 10.[]Electrical repairs or additions I am a homeowner doing all work officers have exercised their myself{No Workers'comp. - right of exemption per MGL 11.O �g repairs or additions insurance �]-1. c. 152, §1(4),and we have no 12. Roof repairs employees, [No workers' .13.0 Other comp.insurance required] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information, f Homeowners who submit this affidavit indicating they are doing all work and then here outside Contractors that check this box mast attached an additional sheet showingmutt submit a new affidavit indicating such. employees. If the sub-contractors have employees,they must r the keys of policy number and state whether or not those entities have provide their workers'comp.policy cumber_ - I am an employer that is providii,Gg workers'com information. pensalion insurance for my employees. Be£ow is the policy and job site Insurance Company Name: P....4.4,-,2_cdt.o . _ Policy#or Self-ins.Lic.#: �6 S�0 5.g � r � Expiration Date: (© Job Site Address: U Li c1 C Attach a copy of the City/State/zi s&. J1.Q•hc.30 1 0 26b y Attach acopy secure er workers'�pensafion policy declaration page(showing the policy number and expiration fine up to$I r covers.00 e squired under Section 25A ofMGL e. 152 can lead to the ' date).a Ere too$1,00 a day one-year imprisonment,as well as o fab STOP of criminal penaltiesn of a' y against the violator. Be advised that a co penalties in the form oe WORK ORDER and a fine investigation of the DIA for insurance coveragecopy of this statement maybe forwarded to the O ff ice of verification. • do hereby certzfy e pairs and penalties ofper.fury that the information provided above is • D. true and Corr • tone# o4s 4b`t t) Date. L LI 2023 • Official use only. Do not write in this . area,to be completed by city or town oZ sty or Town: Permit/License g Aouthority(circle one): # .Board Health 2.BudiagDepaent 3. City/Town Clerk 4.Electrical Other Inspector S.PI mg'. Iltspecor • airier Persoa: Phone ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDNYYY) 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 ONE (Nc.No.Extl: (508)775-1620 X (A/C,No): E-MAIL ADDRESS: Iullivan@doins.com 973 IYANNOUGH RD INSURER(S)AFFORDING COVERAGE NAIC# HYANNIS MA 02601 INSURERA: 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: 775629 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 SUBRI, i POLICY EFF I POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DDIYYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO LOC PRODUCTS-COMP/OP AGG $ JECT 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) $ 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 NV PER X0TH STATUTE AND EMPLOYERS'LIABILITY Y/N ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,000 A OFFICER/MEMBER EXCLUDED? N/A N/A N/A 6S62UB8H08580922 05/10/2022 05/10/2023 (Mandatory in NH) E.L DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $ 500,000 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 amassing 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 Mashpee ACCORDANCE WITH THE POLICY PROVISIONS. 16 Great Neck Road North AUTHORIZED REPRESENTATIVE Mashpee MA 02649 BLS Daniel M.Cro vly,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 The ACORD name and logo are registered marks of ACORD ORD CORPORATION. All rights reserved. ACORD 25(2014/01) ti wvxi `- .�� - t. .-, s. X S -� k - ' w • . i ,r t• it • '11 t t�. • - �4.., .{ 4. to . -741,: , . -..,...-: . t .v _b. :,-.i.*...y� '� • f§, � , er. yes , ,., �g „fete _ f - r a� J•:,;. S,i, r jai eJ -' ., ?i:r ,.*4 1+•• i 4. KELLY ROOFING PH. 508 509 4640 8 RHINE ROAD MA C.S.L. #099167 YARMOUTHPORT MA H.I.C.R. # 128957 Ira' • •., "It' MA 02675 INSURED. Kellyroofing@icloud.com NA March 3'2023 , ' Proposal submitted to Jan O'Brien of 11 Willow Lane South Yarmouth MA. tiff K4.• , 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. F'.. All debris to be removed to town transfer. it c 8"White Aluminum Drip Edge to be installed on all eaves. 5"on 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 Any Valley Areas. : 0.7 — ': rt Remainder of roof deck to be covered with synthetic underlayment. Fr :t; Install limited lifetime warranty architect style Shingles, color to be Weathered Wood To Match . - Existing. ."}. ` ` All shingles to be storm nailed (6) 14' : 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. 4 ; Replace plumbing vent pipe boots with new. %fit Install Ridge Vent with hand nailed caps to Match Existing ., s Complete Clean up off all areas including all gutters and all nails after project complete. 40, ,,,it y` At a total cost of$15,950 To Match Newer Roof Only$12,400 f For Garage Roof Add$7,250. To Match Newer Roof Only$3,300 e' To Replace Existing Skylight Add$1,150 For A Fixed Unit OR$1,450 For A Venting Unit Includes Any Necessary Interior Trim And New Exterior Flashing Kit. " Proposal Submitted by:Oliver Kelly , -e _ C eriatrif-eeA k�,i •:' Proposal accepted by: bn `� O(� Date. 3 / i /2023 yt! � 15 W p6-� ,4 new 66,W Commonwealth or Massachusetts Division of Professional Licensure Board of Building Regulations and Standards ConstructipOad l'ViSpf Specialty • CSSL-099167 Expires: 09/28/2023 OLIVER M KELLY 8 RHINE ROAD YARMOUTH PORT MA 02675 • ,/S t.XO>� f Commissioner aila A. rfam izo— �/2, C�o�/�Z/2ao-/ZC<tea f =G j4/ • c-}-. -cGch'errlP tl 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. iCA 1 0 20M-05/17 c � Office of�ecAf1 irs&usiness Ifegui11tion - 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 710 OLIVER KELLY Boston,MA 02118 OLIVER M.KELLY 9 RHINE RD. �- %` YARMOUTHPORT,MA 02675 Undersecretary Not valid without signat re