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HomeMy WebLinkAboutBLD-23-00070 Y-,`4 6 W ) // r) Office Use Only y�• a 7/'/ /ZZ " 1) Permit# 60310 %, - s1 .431 Amount ��,06 �M AMM ti c , � L, Permit expires 180 days from issue date ,3L-4) - ,,23 --40& d EXPRESS BUILDING PERMIT APPLICA ON TOWN OF YARMOUTH RECEIVED Yarmouth Building Department 0 6 2022 1146 Route 28 juL South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 BUILDING DEPARTMENT Z.N By --_---- CONSTRUCTION ADDRESS: °'1 ti ���G�Q . qA42..M.Q.Ynt ASSESSOR'S INFORMATION: s I Map: Parcel:c+ OWNER: 40W1beat,,t 91 .65 L4Q_ 6. co- kimmo r i iiiit �n d NAME PRESENT�� ADDRESS ,, TEL # r CONTRACTOR: l(b _:t QCti+JG04 k+JG. nn s l>t..a., Y pp _�.0 'tA01t?,�tti 4b2f +'lei- 02b1 NAME MAILING ADDRESS ipp TEL.#p5� `JDg �i(04.0 Residential 0 Commerciale Est.Cost of Construction$ p el U b-� D Home Improvement Contractor Lic.# t2�°t�7 Construction Supervisor Lic.# Oen t.bryo Workman's Compensation Insurance: (check one) 0 I am the homeown r 0 I am the sole proprietor [lr I have Worker's Compensation Insurance Insurance Company Name: Amk,s(i,teakt.S Worker's Comp.Policy#eli '2-0 6SKv4 S tPI 22 WORK TO BE PERFORMED Tent 1___1 Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares 010 ( -Remove existing*(max.2 layers) Insulation El nOld Kings Highway/Historic Dist. 0)Replacing like for like Pool fencing I l ,- *The debris will be disposed of at: ` , i",,, ,,,Q._ 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 ovation of my I , d for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: •j , Date: 7 ) V 1 22. I Owners Signature(or attachmen a' Date: 1 a Approved By: yr t/ Date: 7— 2 Building Official(or des' ee) EMAIL ADDRESS: Zoning District: Historical District: Yes No Flood Plain Zone: • Yes I No Water Resource Protection District: Within 100 ft.of Wetlands: - Yes No -_ Yes No • • SStY; :( jijt f�e 6 4/2w/ o-e di 94/&a.� 6 -ell) 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-05/17Ktym Office of ConsumerAff irs&business Kg;uf5tion 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 i� e - 8 RHINE RD. Not valid without signat re YARMOUTHPORT,MA 02675 Undersecretary • h 'now Jauoiss!wwo0 9L9Z0 VW 1216d H1ROWNVA UY0213NIH218 A173)1 W 213A110 £Z0Z/8Z/60:said:sapdi6 L91.660-1SSD AlieioadS XdstmdRs,•06lon4suo3 spJepuels pue suoueln6a8 6uiplm9;O pueog ainsuaDil leuolssaloid l0 uoisiAip /A sUasngaesseyy{O ylleamuowwo3 A�� DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 05/17/2022 THfS 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 PHONE I(NC,No,Ext): (508)775-1620 ac,No): E-MAIL ADDRESS: ISUIIIVarl d01(1S.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 INSURER C: INSURER D: 8 RHINE RD INSURER B: 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 SUBR , POLICY EFF I POLICY EXP ' LTR TYPE OF INSURANCE I INSD WVD POLICY NUMBER (MM/DO/YYYY) (MM/DD/YYYY)i LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE RENTED CLAIMS-MADE OCCUR PREMISESO(Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GENT 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 I 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 I RETENTION$ $ WORKERS COMPENSATION X I STATUTE OERH AND EMPLOYERS'LIABILITY ANYPROPRIETOR/PARTNER/EXECUTIVE Y/N 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 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/lwd/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 Daniel M. Crowley, 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 DATE(MM/DD/YYYY) A CC)REP 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 poficy(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 WC,N No.Extl: (508)775-1620 FAX No): ADDE-MRESS: Iullivan@doins.com 9731YANNOUGH RD INSURER(S)AFFORDING COVERAGE NAIC# HYANNIS MA 02601 INSURER A: 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: 775628 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- TYPE OF INSURANCE ''ADDL'SUBR POLICY EFF ' POLICY EXP LIMITS LTR INSD wvo POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY] COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTED 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 r—�SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per accidenl) $ NON-OWNED PROPERTY DAMAGE HIRED AUTOS — AUTOS (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ - X STA $ WORKERS COMPENSATION TUTE 0RH AND EMPLOYERS'LIABILITY Y I N ANYPROPRIETOR/PARTNER/EXA OFFICER/MEMBER EXCLUDED?ECUTIVE N/A N/A N/A 6S62UB8H08580922 05/10/2022 05/10/2023 E.L.EACH ACCIDENT $ 500,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes.describe under DESCRIPTION OF OPERATIONS below EL.DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD tot,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 Lakeville ACCORDANCE WITH THE POLICY PROVISIONS. 346 Bedford Street AUTHORIZED REPRESENTATIVE Lakeville MA 02347 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 The Commonwealth of Massachusetts Department of Industrial Accidents R:f,fit, Office of Investigations -F Lafayette City Center 2Avenue de Lafayette, Boston,MA 02111-1750 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information �[ Please Print Legibly Name (Business/Organization/Individual): 11 - 9.O�y ' LL, _ Address:S . K City/State/Zip:'' M£}J PQPS 1 t1 U1—kriS Phone#: Soct 4 040 Are ou an employer?Check the appropriate box: Type of project(required): 1.101 I am a employer with i 4. Q I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g. Q Demolition workingfor me in anycapacity. employees and have workers' P tY• $ 9. Q Building addition [No workers' comp. insurance comp. insurance. required.] 5. ElWe are a corporation and its 10.0 Electrical repairs or additions 3.Q I am a homeowner doing all work officers have exercised their 11.Q Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.EfRoof repairs insurance required.]t c. 152,§1(4),and we have no employees. [No workers' 13.0 Other comp.insurance required.] *My 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 providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: ACE Afteate.A413 Policy#or Self-ins.Lic.#: 66 ()i51,4JO' S?Oq 22, Expiration Date: 5 t0'�23 Job Site Address:21 (SS - i J ea. 20.. City/State/Zip:a, gA.p,M pJ tAA Oa bbt., 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. aiSignature:t , Date:S 7 V/ 2'2_ Phone#: SO SO 4,b4 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 2E1 Building Department 30City/Town Clerk 4.0 Efectrical Inspector 51alumbing Inspector 6.DOther Contact Person: Phone#: