The URL can be used to link to this page

Home My WebLink AboutBLD-23-001770 • I p l / U )c/zi�,,. Office Use Only . `�' 1 Permit# W 3b2i-1 p - i 14 . y Amount c J _" kr �n� M "est:,Z. Permit expires 180 days from b J f) `013 -0/,).,issue date El EXPRESS BUILDING PERMIT APPLIC P V E D TOWN OF YARMOUTH Yarmouth Building Department "I 3 ZOZZ 1146 Route 28 BUILDING DEPARTMENT South Yarmouth, MA 02664 By - ___ (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: a ()V.)L. &,- �'� �'� J ASSESSOR'S INFORMATION: 6C-‘36\AAG--telt,N)Map:y Parcel: n f�OWNER: P4 c-S 0-.Z1 L3?�' ` 'A ZQ_CY02_ NAME PRESENT ADDRESS TEL. # CONTRACTOR: r r t-}--`� e-7 sf—u'J(2-, ( +�i,\e iU e.. ' 0 {AJV )i t,1/4. A r 1A>\ "..j�k,i 1 c NAME MAILING ADDRESS ' TEL.# 5.: `7—.s i,; r{ ii it C: 'Residential 0 Commercial Est.Cost of Construction$ Clit(OD Home Improvement Contractor Lie.# 12 °!-C1 ,A- (7;6 r Construction Supervisor Lic.# ( 7 1 �' Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor I have Worker's Compensation Insurance Insurance Company Name: 4(� 4V. L4 Worker's Comp.Policy#b%L2.tv,e.)‹iit.:13-, 5 o^i 2 WORK TO BE PERFORMED Tent El Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing:t�#of Squares CZ (�)Remove existing* (max.2 layers) Insulation 1 1 Old Kings Highway/Historic Dist. 3 Replacing like for like Pool fencing n t: 44Q4A,p..:)--ri `� Y- The debris will be disposed of a '1 Location of Facility k I declare under penalt L•:4e; per ury •• the statements herein ci ed are true and correct to the best of my knowledge and belief. I understand that any false answer(s) will be just cause for.}r}`►►I. it re icatio of my license. . •, • i •cution under M.G.L.Ch.268,Section 1. Applicant's Signature: t'` . , ` Date: G0 / 3 / 2 2 Owners Signature(or att chmcn Date: 0.'s.2 _ ( Approved By: 'Ili !7 r/ .. Date: G '5---..2 ._ Building Official(or 1•. gn EMAIL ADDRES 1 Zoning District: Historical District: Yes No Flood Plain Zone: Yes No Water Resource Protection District: Within 100 ft.of Wetlands: Yes No _- Yes No _ The Common wealth of Massachusetts —",rr fy Department of Industrial Accidents gi =wi1=i. 1 Cona Tess Street, Suite 100 ca►_ Boston, MA 02114-2017 •.,� www.mass.;ov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly t ' Name(Business/Org .`tion/Individuaf): �.G '- -- ),�j A i..lu t,�- l i 9.3 iiAddress: � ..\A3 �'� ,::, 1 City/State/Zip:1A-1)-)V„ 4'O Q \ ;f4�1 0 Phone #: - `•6 6L 9 `� �(U Are you an employer?Check the appropriate box: Type of project(required): I. ., `am a employer with (. employees(full and/or part-time).* 7_ E New construction 2111 I am a sole proprietor or partnership and have no employees working for me in 8. E Remodeling any capacity.[No workers'comp.insurance required.] 3. I am a homeowner doing all work myself. 9. ❑Demolition ❑ y [No workers'comp_insurance required.]` 10 ❑ Building addition 4.0 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 ernployecs. 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. 00f repairs These sub-contractprs 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. 14.0 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_ ZContractors 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 pro 'ding workers'compensation insurance for my employees. Below is the policy and job site information Insurance Company Name: LIC Policy#or Self-ins.Lic. #: ��ll`` / 1 i Bc�� `� (C1S L (.1 P� t'l 0(I Expiration Date: - L— Job Site Address:3(1 gi,QE S� City/State/Zip: A-(?M c�.0 v/', 02b'712 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration 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 S250.00 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 under th ains and penalties of perjury that the information provided above is true and correct f Signature: Date: i. 10 / 3 / zC____ Phone#: c6 ��i %k. 4'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#: Commonwealth of Massachusetts '®1 Division of Professional Licensure ` / Board of Building Regulations and Standards Constructietrr3tid&i6ytr Specialty CSSL-099167 Expires:09/28/2023 OLIVER M KELLY 8 RHINE ROAD YARMOUTH PORT MA 02675 r :../ Commissioner 4a.16. f. J( • ,w4e ro/74/no-/-4(fitodio/Yga,),..loxA(2/,)-e/7"3- 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 et 20M-05/17 .77e i,iviifv.,//// /�i::air/ /L' Office of Consumer Af�us&business i-6gurrhon 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 (40 LO COI8 RHINE RD. L�"�s6�`� / NOt Valld WIthOUt SlgflBtlre YARMOUTHPORT,MA 02675 Undersecretary AC� DATE(MM/DD/YYYY) 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 PHONNo,Ext): (508)775-1620 (A/C,No): ADDRESS: Iullivan@doins.com 973 IYANNOUGH RD INSURER(S)AFFORDING COVERAGE NAIC# HYANNIS MA 02601 INSURER A: ACE AMERICAN INSURANCE CO 22667 INSURED INSURER B: KELLY ROOFING INC INSURERC: INSURER D: 8 RHINE RD INSURERE: YARMOUTHPORT MA 02675 INSURER F: COVERAGES CERTIFICATE NUMBER: 775624 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. IPOLICY EFF POLICY EXP LT R TYPE OF INSURANCE 'IN DL'VNDUBR POLICY NUMBER (MM/DD/YYYY) IMM/DD/YYYY) LIMITS LTR INSD WVD COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE : $ O E CLAIMS-MADE OCCUR PREMISES(Eaoccur ence) $ 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 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 UAB I OCCUR EACH OCCURRENCE $ EXCESS(JAB CLAIMS-MADE N/A AGGREGATE $ DED • RETENTION 1 $ WORKERS COMPENSATION X AND EMPLOYERS'LIABILITY STATUTE I ER Y ANYPROPRIETOR/PARTNER/EXECUTIVE N E.L.EACH ACCIDENT $ 500,000 A OFFICER/MEMBEREXCLUDED? N/A N/A WA 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 I$ 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 Barnstable ACCORDANCE WITH THE POLICY PROVISIONS. 200 Main Street AUTHORIZED REPRESENTATIVE Hyannis MA 02601 ( C y Daniel M.CroW 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 ACc RO® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/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 INC.No.Ext): (508)775-1620 Fac.No): E-MAIL ADDRESS: iullivan o@doins.Com 973 IYANNOUGH RD INSURER(S)AFFORDING COVERAGE NAIC# HYANNIS MA 02601 INSURER A: ACE AMERICAN INSURANCE CO 22607 INSURED INSURER B: KELLY ROOFING INC INSURER C: INSURER D: 8 RHINE RD INSURER E: _ YARMOUTHPORT MA 02675 INSURER F: COVERAGES CERTIFICATE NUMBER: 775625 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. IPOLICY EFF POLICY EXP NSR TYPE OF INSURANCE IADDL SUBR (MM/DD/YYYY) (MM/DD/YYYY) LTR I I INSD WVD POLICY NUMBER UNITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED I 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 AGG $ 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) 1 • UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ 1 EXCESS UAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION V PER 'OTH- AND EMPLOYERS'LIABILITY Y/N /N STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,000 A OFFICER/MEMBER EXCLUDED, N/A N/A NIA 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 ACCORDANCE WITH THE POLICY PROVISIONS. Town of Bourne 24 Perry Ave AUTHORIZED REPRESENTATIVE Bourne MA 02532 Daniel M.Crowley,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