BLD-23-005793 L—+f—Ca/k
og.Y `11r [,� /n- Office Use
�Only
�, `, i,
' / y �� Permit d t�7(0`�
{O/1 I '4 Amount SW. U
` ATT M'$3 4'. U. 1,M� � E Permit expires 180 days from
,issue date
13tb—L23 dO 57g3
EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department RECEIVED
1146 Route 28 _
South Yarmouth, MA 02664 APR 18 2023
(508) 398-2231 Ext. 1261
-� BUILDING DEPARTMENT
CONSTRUCTION ADDRESS: `/�5 �' S �' A. (Jti�T `R By
ASSESSOR'S INFORMATION:
Map: Parcel//:��-- ,�,/
OWNER: S /0i 43 lq /3 s 50. $�lA2aT U�. �. i'¢? 9JFif ,i4 02 y
NAME ((�� (� PRESENT ADDRESS TEL. #'7711 23$ �
CONTRACTOR:)Li,1`L.2-- lki.U-'1 e7 KL1i.NE.QIAt) '(AlmsJIM(VAS vt - 021c 1 NAME MAILING ADDRESS TEL.#7y 508 SEA Sl6qa
�Residential 0 Commercial Est.Cost of Construction$ 35'"'0''0
Home Improvement Contractor Lic.# I 2_ & 7 Construction Supervisor Lic.# c(11)7
Workman's Compensation Insurance: (check one)
D I am the homeowner A 0 I am the sole proprietor 7I Worker's Compensation Insurance,
Insurance Company Name: AC-6Worker's Comp.Policy#6JUZI)2 S UD 5St oW 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 6 (M)Remove existing*(max.2 layers) Insulation El
riOld Kings Highway/Historic Dist. 4 Replacing like for like Pool fencing n
*The debris will be disposed of at: � -"M ` ,2� �
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 revocation of m I' se and for prosecution under M.G.L.Ch.268,Section 1. 9
Applicant's Signature `. G `L Date: 41' IS- 2-0 L3
Owners Signature(or attachment) Date: !�
Approved By: Date: / .'/,.6Z
Building Official(or i EMAIL AD S:
Zoning District:
Historical District: ❑ Yes ❑ No Flood Plain Zone: C Yes C No
Water Resource Protection District: Within 100 ft.of Wetlands:
❑ Yes ❑ No ❑ Yes ❑ No
A�o® CERTIFICATE OF LIABILITY INSURANCE DATE(NIAVDD/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 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 (Arc.(;_ l: (508)775-1620 FAX
UM.
ADDRESS: Isuilivan@doins.com
973 IYANNOUGH RD INSURER(S)AFFORDING COVERAGE NAIC P
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. NOTIMTHSTANDING 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 POLICY EXP
I. TYPE OF INSURANCE ADM
,JNVD POLICY NUMBER (MMIDDI POUCYYYYI IMMIDD//YYYYY) 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 JECT LOC PRODUCTS-COMP/OP AGG $
OTHER: $
AUTOMOBILE LIABIUTY COMBBIINEEDt SINGLE LIMIT $
(Eaiden
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 UAB _ OCCUR EACH OCCURRENCE $
- EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $
DED RETENTION$ $
WORKERS COMPENSATION X STATUTE OER
TH-
AND EMPLOYERS'LIABIUTY Y/N
ANYPROPRIETORIPARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,000
A OFFICER/MEMBEREXCLUDED7 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 E.L.DISEASE-POLICY LIMIT $ 500,000
DESCRIPTION OF OPERATIONS below
N/A
DESCRIPTION OF OPERATIONS I LOCATIONS I 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
ACCORDANCE WITH THE POLICY PROVISIONS.
Town of Yarmouth
534 Winslow Grey Road AUTHORIZED REPRESENTATIVE
South Yarmouth MA 02664 Dan el M.Cr o y,CPCU,Vice President—Residual Market—WCRIBMA
0 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
•
` . The Commonwealth of Massachusetts
• 1
_+ , _ i Department of Industrial Accidents
_L/11:= 1 Congress Street, Suite 100
_F�_S' Boston, MA 02114-2017
5.•' www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information � ,,V'�� Please Print Legibly
A(�[Name (Business/Organization/Individual): - / 6 Z� L
Address: g LitiV .
City/State/Zip: Yomoopty4- 02675Phone #: g $ 46 qo
Are you an employer?Check the appropriate box: Type of project(required):
l. m a employer with employees(full and/or part-time).* 7. New construction
2.0 I am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling
any capacity.[No workers'comp.insurance required.]
3.❑I am a homeowner doing all work myself. [No workers'comp.insurance required.]t
9. ❑ Demolition
10 ❑ Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.❑ Electrical repairs or additions
proprietors with no employees. _ 12.❑Plumbing repairs or additions
5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.[ Roof repairs
These sub-contractors have employees and have workers'comp. insurance.;
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.El Other
152,§1(4),and we have no employees. [No workers'comp. insurance required.]
*Any 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 prc iding workers'compensation insurance for my employees. Below is the policy and job site
information.
hitealeA
Insurance Company Name:'/ (26 d GC
Policy#or Self-ins.Lic. #: Y)2 '&2_.0 f8 Ll,® Z�J8- 2,2Expiration Date: S ./0 '23>
Job Site Address: 135 SC)' C LrO.'C /'V 17 City/State/Zip: e 0
Attach a copy of the workers' compensation policydeclaration ashowing the policynumber and ex irati�P P b ( b p n date).
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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$250.00 a
day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify un', t .ains and penalties of perjury that the information provided above is true and correct.
Signature: r `l t (c$ `
Date:
Phone#: 50q 3. 1/6 O'
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone#:
g"-.4 6/712/220-/MOdi.074/g0:44-ffele(4-ei
Xi
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.
SCA 1 0 20M-05/17
..T! ,/nnirw/Pe(r.f1 17 CJi ifi
Office of Consumer dit / usiness'tegurrMtion
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
Boston,MA 02118
OLIVER KELLY
OLIVER M.KELLY Q0--Q--' ts-CD C°1
YARMOUTHPORT,MA.02675 Not valid without signature
Undersecretary
•
Ilf Commonwealth of Massachusetts
Division of Professional Licensure - k
Board of Building Regulationsat �_ and Standards
Constructvj�'�t'`S J'cfi r Specialty
f
CSSL-099167 r 1pires:09/28/2023
•` OLIVER M KI.LY' --
ill
8 RHINE RO .1" r X
YARMOUTH ;t1i,,14,441,%" r
\ Oiiss9
Commissioner di,�•, t itnae.,
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@idoud.com
April 6, 2023 5e c..5:
Proposal submitted to TCt a Owners Of Unit 7A, 135 South Shore Drive, South 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"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, In
Valley Areas and around all protrusions.
Remainder of roof deck to be covered with synthetic underlayment.
Install limited lifetime warranty architect style Shingles, color to be Weatheredwood ,
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. 1
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$3,500
Proposal Submitted by:Oliver Kelly
JAF
Proposal accepted by- Date. L/ / 9 /2023
Best Contact Pho : a y—2,3$'- O d O
This proposal is valid for 30 days from date above, please call to verify thereafter.