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HomeMy WebLinkAboutBLD-23-006054 LJ / ,57W/oZ3 office Use only `: -7. Permit# Lam" t/(0J9 0.te ;`S Amount 5-d.do ";,,, , $ Permit expires 180 days from `, issue date ,3 D-a3 - t D4fa5L1 EXPRESS BUILDING PERMIT APPLICA = c:p C E i V 0 TOWN OF YARMOUTH __- Yarmouth Building Department ° MAY 243 1146 Route 28 1 South Yarmouth,MA 02664 -... BUILDING DcNARTMENT 1 (508)398-2231 Ext. 1261 By - ----- CONSTRUCTION ADDRESS: ' S V.,1900 6 61P . LtAtea-4;;ONA. X- ASSESSOR'S INFORMATION: Map: 1(6 Parcel: OWNER(( 4I 4Pr (-714 i Ot,Nl 36 i oc�+,.dt 'yR. -51-1-lDoLr MA o265-7S NAME PRESENT ADDRESS TEL #'7a(44Z4 4.1 i 2;� CONTRACTOR: tkE `' r t(�lty 4A* e Gt MA 02(07-5 NAME MAILING ADDRESS TEL.#. v4S SO 1 4 W.a H(Residential 0 Commercial Est.Cost of Construction$ /4$i)O Home Improvement Contractor Lie,# i2-55ck Construction Supervisor Lic.# c S t b 7 Workman's Compensation Insurance: (check one) 0 i am the homeowner I] I am the sole proprietor Q I have Worker's Compensation Insurance Insurance Company Name: (CA!.&raQMAA Worker's Comp.Policy# 64 606 vto 6 SS CA 2.Z WORK TO BE PERFORMED Tent [J Duration (Fire Retardant Certificate attached?) Wood Stove ❑ Siding: #of Squares Replacement windows:# Replacement doors: # Roofin : #of Squares 2( (Eli Remove existing*(max.2 layers) Insulation ❑ vigOld Kings Highway/Historic Dist. Replacing like for like Pool fencing ❑ �i n d„ 11 1\Kt t' 5�ZEptAcaa6- cx 3-u�Q A Qt AIS Reo� 0 r'm mac,W teu trt.c5�tkoGLE *The debris will be disposed of at: Af11 IAA4 3 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 revs ;,. t f my license and for prosecution under M.G.L.Ch.268,Section 1. '2_— �_se J Applicant's Signature° 0 t Date: 5 (Owners Signature(or attachment) Date' Date: 5 = '�-3 Approved By: EMAIL AD Building Official(or .. Zoning District: Historical District: 7 Yes No Flood Plain Zone: 7 Yes := No Water Resource Protection District: Within 100 ft.of Wetlands: / Yes No 1 Yes _. No , i 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 April 3'2023 Proposal submitted to Dan&Tina Chisoim of 35 Knollwood Drive, Yarmouthport, 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"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 around all protrusions. 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. Replace All Step Flashings With New When Replacing Rake Boards, Replace All Chimney Flashing 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$10,800 Replace All Rake Boards With Composite Trim Boards Add $2,325 Remove Gutters And Replace All Fascia Boards With Composite Tim Boards Add $1,400 Payment Due Upon Completion. Proposal Submitted by: Oliver Kelly 2Avenue de Lafayette,Boston,MA 02111-1750 www.mass.gov/dia Workers'Compensation Insurance Affidavit; Builders/Contractors/Electricians/Plumbers Aimlicant Information Please Print Legibly Name(Business/organization/Individual): 'l\. .Lt.. .1 Address: L1/44.1C-. Q-0.,Pktv City/State/Zip: 'at? .iilki)c,a-C EAR CY)67S Phone#: 5CA <<b4.O Are you an employer?Check the appropriate box: Type of project(required): I. I am a employer with t 4. 0 I am a general contractor and 1 Q employees(full and/or part-time).* have hired the sub-contractors 6. New construction 2.0 I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub-contractors have 8. Q Demolition working for in employees and have workers' any capacity. i 9. ❑Building addition [No workers Cu comp.insurance rnp• nsurance.'' required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3.0 I am a homeowner doing all wuik officers have exercised their 11.0 Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12.E RRttof repairs insurance required.]t c. 152,§1(4),and we have no employees. [No workers' 13.0 Other comp.insurance required.] *Any applicant that checks box d I 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 indirsning 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. Ack.,-.Insurance Company Name: % Policy#or Self-ins.Lie.#: bf 6:12-t$9)85'd Ct ZZ Expiration Date: 5't. -23 Job Site Address:35 L4&)CALL(06)D v2 City/State/Zip:4A4-440,)r14 c✓!L 11 (O2e✓75 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 hue and correct. Signature: G•k.JA Date: .6 I 2 2023 Phone#: So I) 501 L 6c4.C) 1 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 29 Building Department 30City/I'own Clerk 4.0 Electrical Inspector 5Ek'hnnbing < Inspector 60Other j Contact Person: Phone#: Commonwealth or Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Constructiotr$0Ae SQr Specialty • CSSL-099167 Expires:09/28/2023 OLIVER M KELLY 8 RHINE ROAD YARMOUTH PORT MA 02675 • " `a= • Commissioner ficIA 1. C C init.. a e C90/22m220/W-Lez l 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 Cl 20M-05/17 Office of C IMPROV fME &1i' inTRA TgdWon Registration valid for individual use only HOME IMPROVEMENT CONTRACTOR _ „ ,before the expiration date. If found return to: TYPE:i Individual Office of Consumer Affairs and Business Regulation Registration 06 13/202Expiratio 1000 Washington Street -Suite 718 ?28957 06/13/2023 Boston,MA 02118 OLIVER KELLY OLIVER M.KELLY �� %%ter s RHINE RD. Not valid without signet re YARMOUTHPORT,MA 02675 Undersecretary ACo CERTIFICATE OF LIABILITY INSURANCE DATE(MWDD"YYY) kiii..----- 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 tmNo.Ext):• (508)775-1620 FAX fAIC.Nol: ADDRESS: lsullivan@doins.com 973 IYANNOUGH RD INSURER(S)AFFORDINGCOVERAGE NAICO 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: 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 ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD wvn POLICY NUMBER IMMIDD/YYYYI (MM/DWYYYYI LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ HJECTPOLICY PRO LOC PRODUCTS-COMP/OP AGO $ 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$ / $ X WORKERS COMPENSATION ST TUTS OTH- AND EMPLOYERS'UABILITY Y/NER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,000 A OFFICER/MEMBER EXCLUDED? NIA 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 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 Daniel M C y,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