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HomeMy WebLinkAboutBLD-23-006056 Ca7 I 0 '�/i-dv3 z6, 1/ permit espsres 180 days from issue date gti—a3 EXPRESS BUILDING PERMIT APPLICA ONE D E 1 V E D TOWN OF YARMOUTH Yarmouth Building Department I MAY 0 2 2023 1 146 Route 28 South Yarmouth,MA 02664 BUILDING DEPARTMENT (508) 398-2231 Ext. 1261 By ------ CONSTRUCTION ADDRESS: 12_ c tSt1 W A W\e chi qiNZI‘kaAtk ASSESSOR'S INFORMATION: Map: Parcel: OWNER:QO € n wtt,1 12 St-cu lsist{ to `1 0- OJT AA 026/3 NAME PRESENT ADDRESS TEL. # j0S 360 /b/S CONTRACTOR: IA,VeAX E O__ - PJAkAZ { 1.411, ,a:U MA O2-615 ��// NAME MAILING ADDRESS TEL#SG C SG Ct 4l t3 Ex 1QResidential OCommercial Est.Cost of Construction SIA 00 Home Improvement Contractor Lie.# t 2.. � Construction Supervisor Lie.# CAC(t b 7 Workman's Compensation Insurance: (check one) / D I am the homeowner 0I am the sole proprietor U I have Worker's Compensation Insurance Insurance Company Name: Ckte AM )Q)CA4Worker's Comp.Policy# 6 6(0tt is S 5 O ZZ- WORK TO BE PERFORMED Tent D Duration (Fire Retardant Certificate attached?) Wood Stove Q Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares 10 (j Remove existing*(max.2 layers) Insulation 1 t El Old Kings Highway/Historie Dist. Replacing like for like Pool fencing I 1 *The debris will be disposed of at: qAtle"")."1 Location of Facility I declare under penalties of perjury that the statements herein contained are true and correct to the best of my Imowledge and belief. I understand that any false answer(s) will be just cause for denial or rev. ;•. .f my license and for prosecution under M.G.L.Ch_268,Section 1. 2 Applicant's Sign � Date: 5 ( 2 ic Owners Signature(or attachment) Date: Approved By: r! Date. 3 Building Official(or desi EMAIL ADDRESS: w` Zoning District: Historical District: .{ Yes No Flood Plain Zone: - Yes - No Water Resource Protection District: Within 100 ft.of Wetlands: Yes No . Yes No zy = 2Avenue de Lafayette,Boston,MA 02111-1750 www.mass.g©v/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Oi- Name(Business/Organirttirrn/IndividtraI�: �ti �.`t ( th�Cx Adams: ZIAA,NA. (4.0..A1) City/State/Zip: q s pc,4yc 41 026757 Phone#: 50q. Libito Are you an employer?Check the appropriate box: Type of project(required): 1.[f I am a employer with t 4. al am a general contractor and 1 6 New construction employees(full and/or part-time).* have hired the sub-contractors 2.0 I am a sole puprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub-contractors have g_ D Demolition employees and have workers' working forme in any 9. ❑Building addition [No workers comp.insurance comp.insurance,: required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3.D I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself[No workers' comp. ri J r t of exemption per MGL 12.1RrRoof repairs insurance required.]t c. 152,§1(4),and we have no 13.0 Other employees. [No workers' comp.insurance required.] *Any applicant that cheeks 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. tContractors 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 my employees. Below is the policy and job site information. Aivtx..--'41ACA4Insurance Company Name:AU-1. Policy#or Self-ins.Lic.#: (05 62-u 9"085 27--- Expiration Date: 5 -23 Job Site Address: /2 of l ki'' City/State/Zip: �� �'4QM O J TL( ✓��I 0267� 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 under the pains and penalties of perjury that the information provided above is true and correct. Signature: G Lak Date: .S 1 2- ( 2 a 23 Phone#: SO S 5D9 t'f,bk{0 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): IDBoard of Health 20 Building Department 3lCity/rown Clerk 4.0 Electrical Inspector 5.ralumbing Inspector 6.DOther Contact Person: Phone#: ' i W0/22/ 20-/-4,10eCal / // cc% ó&2: Office of Consumer Affairs and Business Suite 7 Regulation a 1000 Washington Street 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. 5CA 1 0 20M-05/17 C- r e of Consumer// ,rJ-a./i Officeof IMPROVEMENT�� �usNTR ffeg R Registration valid for individual use only HOME CONTRACTOR before the expiration date. If found return to: TYPE:Individual Office of Consumer Affairs and Business Regulation Reaisb57 06 i7023 WDD Washington Street -Suite 710 128957 Boston,MA 02118 OLIVER KELLY.`; OLIVER M.KELLY ,4.i2. Not valid without signs re Q(2S2—, 8 RHINE RD. YARMOUTHPORT;MA 02675 Undersecretary Commonwealth of Massachusetts �r Division of Professional Ucensure _ Board of Building Regulations and Standards Constructi\ 'S .plAI•ViSpr Specially 's • CSSL-099167 pires:09/28/2023 OLIVER M KELLY z: r 8 RIME ROAD 1,• YARMOUTHfa RTABR, BS:75 % wC a _- Commissioner din t i. UG.1c a- A e CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY)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 polioy(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 CONTACTNAME: Linda Sullivan DOWLING&O'NEIL INSURANCE AGENCY imcPHOONNL,E,�: (508)775-1620 FAX.Ne): ADDRESS: Isulliivan(i doins.com 973 IYANNOUGH RD INSURER(S)AFFORDING COVERAGE NAB 0 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 INSURER F: COVERAGES CERTIFICATE NUMBER: 775626 REVISION NUMBER: THIS IS TO THAT THEOF INSUCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY INDICATED.CERTIFY NOTWIT STANDING ANY ES REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH PERIOD S 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 SUER POLICY NUMBER (MN DDYDIYYI YI IMM/DD/YYYYI LIMITS POUCY EXP LTR TYPE OF INSURANCE ono W VD 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 $ PRO- POLICY JECT LOC PRODUCTS-COMP/OP AGO $ $ OTHER: COMBINED SINGLE LIMB $ AUTOMOBILE LIABILITY (Ea accident) BODILY INJURY(Per person) $ — ANY AUTO ALL OWNED — SCHEDULED N/A BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS _ AUTOS (Per accident) $ UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE N/A AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION X I STATUTE I I ER - AND EMPLOYERS'LIABILITY Y/N E.L.EACH ACCIDENT $ 500,000 AFFICER/M MBER EXCLUDED? /DXECUTIVE I N/AI N/A N/A 6S62UB8H08580922 05/10/2022 05/10/2023 A (MandatoryaR/MEMNH)EXCLUDED? E.L.DISEASE-EA EMPLOYEE $ 500,000 in NH) If yes describe under E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS below N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) rsement calla ms for benefits to employees in will s be tates othaid er than Massachusett employees t e insured hires,or hasuant to nhiredhose employees outside of Massacion is husetts. This en to pay 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.govllwd/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 ACCORDANCE WITH THE POLICY PROVISIONS. Town of Dennis PO Box 2060-485 Main Street AUTHORIZED REPRESENTATIVE (—L.-Aj c,ic South Dennis MA 02660 Daniel M.Cr y,CPCU,Vice President—Residual Market—WCRIBMA 01988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD • KELLY ROOFING PH. 508 509 4640 8 Rhine Road MA C.S.L. # 099167 Yarmouthport MA H.i.C.R. # 128957 MA 02675 - April 24'2023 Proposal submitted to Mr. Bob Goodwin of 12 Standish Way, West Yarmouth MA. 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. All debris to be removed to town transfer. 8" White Aluminum Drip Edge to be installed on all eaves. 5" On All Rakes. Ice and Water damage protection membrane to be installed on first Six feet of all eaves and around all protrusions. Remainder of roof deck to be covered with synthetic underlayment. Install limited lifetime warranty Architect style Shingles, color to be specified, Sc-e All shingles to be storm nailed (6)We Generally Use Certainteed Products with All Accessories 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$4,800 Remove Existing Chimney And Fill Area With 5/8" Plywood. Add $250 Please Sign Here To Attest to The Chimney And Fireplace Being Removed And No Longer Being in Use. We Accept No Responsibility For Fireplace Use And Any Possible Subsequent Damage Caused After Chimney Removal Homeowner Accepts Responsibility For Adherence To All Code Requirements For Fireplace and Chimney Removal. Signed: Mr. Robert Goodwin. Date y l.25/ /2023 Payment Schedule;Balance upon Completion Proposal Submitted by: Oliver Kelly