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HomeMy WebLinkAboutBLD-23-003423 COI 6 1?AZ(irL Office Use Only D1'YAR'tt . ' a Perntit `7 �, Q .410 , „A.__ �yy a - Amount , s, I Permit expires 180 days from ;ft.,::-'` issue date 6LID -6)..3 -d®3 tt?3 EXPRESS BUILDING PERMIT APPLICAT TOWN OF YARMOUTH RECEIVED Yarmouth Building Department 0 2022 1146 Route 281 DEC South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 BUILD1t�G p( PARTMENT CONSTRUCTION ADDRESS: 6( �t2411 g U l� S I . � JEV- qiscAllioiJ _ry _,� -- -- ASSESSOR'S INFORMATION: Map: Parcel: OWNER: ' tA'(bi VIE,Ng\oa 31) t✓1 W- -Nvct-tN �y £• 6•A r 0 Z 7 5 NAME PRESENT ADDRESSC TEL. # i So L1 bC4_0 CONTRACTOR: '7 i ,*"1 CD C-LA G to -' --i3_ ikilm. a 4. C C s AAA Oa el.c NAME MAILING ADDRESS ' TEL.#5c e 70 r ti b ti f; 'Residential 0 Commercial Est.Cost of Construction$ (4 00 �' 1 J Home Improvement Contractor Lic.# 121-61-C1 Construction Supervisor Lic.# (1fi i Workman's Compensation Insurance: (check one) 13 I am the homeowner ❑ I am the sole proprietor �1 I have Worker's Compensation Insurance Insurance Company Name: 4C . 4f- , Worker's Comp.Policy#t 1 %4. ;f`� C" z0714 I WORK TO BE PERFORMED Tent 1.J Duration (Fire Retardant Certificate attached?) Wood Stove U Siding: #of Squares Replacement windows:# Replacement doors: # Roofing:/#of Squares 2-0 (E')Remove existing*(max.2 layers) Insulation i l i J Old Kings Highway/Historic Dist. 4 Replacing like for like Pool fencing I I The debris will be disposed of at: 14 n 1 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 revocation of my licens d for prosecution under M.G.L.Ch.268,Section 1. , Applicant's Signatu 1 ' — Date: 12- / (9 if 2Z j Owners Signature(or attachment Date: Approved By: 16 Date: — -2012- Building Official(or desi ee) EMAIL ADDR 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 Commonwealth of Massachusetts -_" Department of Industrial 3 - Office of Investigations 'j __ . Lafayette City Center `_ ''-' •.. �• ` 2 Avenue de Lafayette, Boston,MA 02111-1750 www.mass gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information g Please Print Legibly Name(Business/Organization/Individual): `��e '` \ lAle Address: a City/State&Zip:' J'I1( `; Pik O 1S Phone#: 5o 2. 5o0i 464,0 — Areyou an employer?Check the appropriate box: Type of project(required): 1.1?. I am a employer with 11 4. 0 I am a general contractor and I employees(full and/or part time). * have hired the sub-contractors 6. El 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. 0 Demolition working for me in any capacity. employees and have workers' o workers' insurance.t 9. El Building addition [No comp.insurance comp.required.] 5. 0 We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12. Roofrepairs 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#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. *Contactors 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. lithe 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. i Insurance Company Name: �z� Policy#or Self-ins.Lic.#: 65 0 45 .,`6?Oq 2. . Expiration Date:-6 e(0' Job Site Address:6 f AX 1,1 Al Si% 6,---.. City/State/Zip: a , r4P-Af O-J rt./ 002673 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 L` iL Signature:0, i 2/_ A Date: l2 /1 /9 _ l Phone#: 5045 SO A W 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): I❑Board of Health 20 Building Department 3❑City/Town Clerk 4.0Etectr'ical Inspector 5Elumbbing Inspector 6.0Other Contact Person: Phone#: 1 ® DATE(MM/DDIYYYY) A�o 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 PHONE.F ); (508)775-1620 FAX (A/C, EMAIL Iullivan doins.com ADDRESS: C 973 IYANNOUGH RD INSURER(S)AFFORDINGCOVERAGE NAIC# 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 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. ICY EXP NSR ADDLTYPE OF INSURANCE INSD SLID POLICY NUMBER (MM//DCYD/YYYY1 (MMIDO/YYYY) LIMITS LTR INSD WVD COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEM_AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: AUTOMOBILE UABILITY COMBINED ANYLIMIT $ ANY AUTO BODILY INJURY(Per person) $ — — ALL OWNED SCHEDULED AUTOS N/A BODILY INJURY(Per accident) $ _ AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS _ AUTOS (Per accident) $ UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION V. PEATUTE ER OTH AND EMPLOYERS'LIABILITY Y/N ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,000 A OFFICER/MEMBEREXCLUDED? N/A N/A N/A 6S62UB8H08580922 05/10/2022 05/10/2023 E.L.DISEASE-EA EMPLOYEE $ 500,000 (Mandatory in NH) t yes,desaihe 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) 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 Dennis PO Box 2060-485 Main Street AUTHORIZED REPRESENTATIVE f , c,S South Dennis MA 02660 Daniel M.Cr*fey,CPCU,Vice President—Residual Market—WCRIBMA I ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Constructioir`SiIplervisor Specialty CSSL-099167 Expires:09/28/2023 OLIVER M KELLY 8 RHINE ROAD a YARiOKIOUTH FY)RT MA 82675 r tiW1.10 Commissioner Olin f;. U&ic. 6.72-4,2wimpeade o/Alea.j.jac4aei",/.`) 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 v 20M-05/17 //Office of Consumer Af airs dusiness fteguu1Stion 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 06ff312023 1000 Washington Street -Suite 710 Boston,MA 02118 OUVER KELLY OUVER M.KELLY ni16411111k 410° 01:;01 8 RHINE RD. (�.,- 'C f� Not valid without signatire YARMOUTHPORT,MA 02675 Undersecretary KELLY ROOFING PH. 508 509 4640 8 Rhine Road MA C.S.L. #099167 Yarmouthport MA H.I.C.R. # 128957 MA 02675 INSURED November 7'2022 Proposal submitted To Mary Henderson of 61 Franklin Street Extension, 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. All Roof Decking Secured Ice and Water damage protection membrane to be installed over first six feet of all eaves and over complete lower pitched roof area. Remainder of Roof Deck to be Covered with Synthetic Underlayment Install Certainteed Landmark limited lifetime warranty Architect style Shingles, Using all Certainteed Starters and Cap Shingles to maximize available warranties, (Color to be Specified) All shingles to be storm nailed (6) Repair all flashings as necessary. Install Certainteed Filtered ridge Vent on All Ridges with hand Nailed Caps Replace all Plumbing Vent Pipe Boots With new. Complete Clean up off all areas including all gutters and all nails after project complete. Obtaining Of Town Permit At a total cost of$9,400 'Ficir--SbekliloaAcIcr$46 .. Ettiwat ana ESLI V1S6-1( al4)ften Payment Schedule; Balance upon Completion Proposal Submitted by: Olive elly Proposal accepted by/ a1 Date. `al j[/ 12022 Best Contact Phone Number: