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HomeMy WebLinkAboutBLD-23-003426 Ca•Atli 121 ii 1 t Office Use Only �° .Y �� Pry ZOI- ioZ ',,rz ° ,Amtoum SO AO . • -� Permit expires 180 days from ' 1 issue date 6 CA)—:3 -b j 3LjZf EXPRESS BUILDING PERMIT APPLICA O?E C E 1 V F D TOWN OF YARMOUTH Yarmouth Building Department DEC 2 ZO22 1146 Route 28 South Yarmouth,MA 02664 (508)398-2231 Ext. 1261 LBY1LTMENT/_ CONSTRUCTION ADDRESS: UJe 0 267 - ASSESSOR'S INFORMATION: t 1)ei 3 w b r. Map: Parcel: OWNER: RC1 (R S��L 7 cCfe,� C i.� u c7G�j 673 PREEN NAME ST ADDRESS TEL.M A '7 7 tA LI K U6j CONTRACTOR: �'LA>1 C-u0 ra 46 2.1A‘Nio (` A 6 *Amoantabgi IAA 02bi S NAME MAILING ADDRESS I TEL 4 #$o g 50 9 4 b 40 / Qr I�JResidc tial OCotnmmercial Est.Cost of Construction$ f o.° Home Improvement Contractor Lic.# 12 O s1 Construction Supervisor Lie.# -/I e7 Workman's Compensation Insurance: (check one) 01 am the homeowner 0 I am the sole proprietor g 1 have Worker's Compensation Insurance S620EsSttO SS0/Z ��Company Nam; 403 CqN Worker's Camp.Policyll Z WORK TO BE PERFORMED Tent El Duration (Fire Retardant Certificate attached?) Wood Stove El Siding: #of Squares Replacement windows:# Replacement doors: # Roofing:t/#of Squares la ([S Remove existing*(max.2 layers) Insulation 1-1 11 Old Kings Highway/Historic Dist. 0 Replacing like for like Pool fencing ❑ 'The debris will be disposed of at 1AMSt. t 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 answet(s) will be just cause for denial or ' of my license 'at under M.G.L.Ch.268,Section I. Applicant's S ,' Date it i 1 CA i 2.2_ Owners Signature(or attachment) / ----2______-Date: `2 / I (/ 1B EMAIL r r 4� Building Offs ' of"Wince) �r Zoning District: 1 Historical District: G Yes _] No Flood Plain Zone: r Yes E No Water Resource Protection District Within 100 ft.of Wetlands: r_ Yes u No Z Yes Z No �'' , The Commonwealth of Massachusetts Department oflndustrialAccidents ''-1-,, Office of Investigations =.,— - ►,, Lafayette City Center 's;,' = 7; 2 Avenue de Lafayette, Boston,MA 02111-1750 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly g Name(Business/Organization/Individual): "LAAT„7- 6c.4 Address: t City/State/Zip: MmC•1 5- 02-0G Phone#: 50 f5 50q 4 640 Are,you an employer?Check the appropriate box: i general contractor and I Type of project(required): l. 4. am a I am a employer with 1g 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub-contractors have S. ❑Demolition working for me in any capacity. employees and have workers' 9_ 0 Building addition [No workers' comp.insurance comp.insurance.: required.] 5. 0 We are a corporation and its 10.0 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.jrRoof 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#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: Ack: Acio• Policy#or Self-ins.Lic.#: Cs < o 6'6l 1 5` Oq 2.2_ Expiration Date:_6 o(0'2-023 Job Site Address: U A"f 23 k EA-DOA-IV-6 -DO_ City/State/Zip: 0 --r`''(MAi Ate? 0� 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 cernify under the pains and penalties of perjury that the information provided above is true and correct Signature:b, ' Date: Ii- 11 i 9 I Phone#: 50.5 504 4,644,0 - y 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): iDBoard of Health 20 Building Department 30City/Town Clerk 4.QEfectrical Inspector 51:1F'lumbing Inspector 6.[]Other Contact Person: Phone#: , ACo D CERTIFICATE OF LIABILITY INSURANCE DATE( Y) � 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(les)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). PRODUCERCONTACT Linda Sullivan DOWLING&O'NEIL INSURANCE AGENCY wcPHONENoE,. �L : (508)775-1620 FAX (A/C, A"�ESS: Isuliivan@doins.com 973 IYANNOUGH RD INSURER(S)AFFORDING COVERAGE NAIC0 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: 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. ADDL SUER POLICY EFF POLICY EXP UNITS LTRR TYPE OF INSURANCE MD WIWD POLICY NUMBER tMMIDD/YYYY) (MM/DD/YYYY) COMMERCIAL GENERAL UABIUTY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ MED EXP(My one person) $ N/A PERSONAL&ADV INJURY $ GEM.AGGREGATE OMIT APPLIES PER: GENERAL AGGREGATE $ PRO- POLICY JECT LOC PRODUCTS-COMP/OP AGG $ $ OTHER COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY (Ea accident) $ BODILY INJURY(Per person) $ _ANY AUTO ALL OWNED — SCHEDULED N/A BODILY INJURY(Per accident) $ NON-0 AUTOS AUTOS N/A PROPERTY DAMAGE T (Per accident) $ HIRED AUTOS _ AUTOS $ UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION S $ WORKERS COMPENSATION X PE TH- RTUTE O R AND EMPLOYERS'UABIUTY Y/N E.L.EACH ACCIDENT $ 500,000 AFFICER EMBE EXCLUDED? l N/Al NIA N/A 6S62UB8H08580922 05/10/2022 05/10/2023 A (Mandatory in NER EXCLUDED? E.L DISEASE-EA EMPLOYEE $ 500,000 (Mandatory in NH) It yes,describe 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) ant to nt cWorkers'laims forbenefits to employees in ion benefits will state be s otherfd than Massachusetts Massachusetts employees the insured hires,or has hiredthose employees outside of Massacion is husetts. This en to pay 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.govAwd/workers-compensationfinvestigations/. 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 D."i South rm Yaouth MA 02664 Daniel M.Croy,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD f � e 0722/2zoimo-eadi o-,,./&-c44-JacZateaf.) 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 LL //Office of Consumer A sirs 8�usiness U Mtion 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 8 RHINE RD. '/ Not valid without signat re YARMOUTHPORT,MA 02675 Undersecretary Commonwealth at Massachusetts i Division of Professional Licensure Board of Building Regulations and Standards ConstructiorobuptervIspr Specialty - CSSL-099167 EApires:09/28/2023 OLVER M KELLY , f. r 8 RHINE ROAD YARMOUTH PART MA.02675' Commissioner ala fi. t3tvnc!! . - r- I DATE(MDDNYYY) AC0 Mt CERTIFICATE OF LIABILITY INSURANCE 05n7/2022 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(les)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). CONTACT PRODUCER NAME: Linda Sullivan FAX DOWLING&O'NEIL INSURANCE AGENCY (Am.PHONE .Exn: (508)n51620 (A/C,No): E-MAILDDRIsullivan@doins.com 973 IYANNOUGH RD INSURER(S)AFFORDING COVERAGE NAIC II HYANNIS MA 02601 INSURER A: ACE AMERICAN INSURANCE CO 22667 INSURED INSURER B: KELLY ROOFING INC INSURER c: INSURER D: 8 RHINE RD INSURERE: YARMOUTHPORT MA 02675 INSURER F: COVERAGES CERTIFICATE NUMBER: 775630 REVISION NUMBER: THIS IS TO CE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE INDICATED.CNOTWITTHAT TANDING ANY ES REQUIREMEOF NT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TOLICY WHICH PERIOD S 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 REDUCEDBY PAID CLAI POLICYMS. ueiTs INSR ADM SUER POUCY POLICY NUMBER (MMIDDIYYTY) (MMIDDJYYYY) LTR TYPE OF INSURANCE NODW VD COMMERCIAL GENERAL LIABIUTY EACH OCCURRENCE $ DAMAGE-10 RENTED CLAIMS-MADE I I OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GE _L AGGREGATE LIMIT APPLIES PER:POLICY I I PRODUCTS-COMP/OP AGO $ JECT LOC $ OTHER: COMBINED SINGLE LIMIT $ AUTOMOBILE LIABILITY (Ea ardent) BODILY INJURY(Per person) $ ANY AUTO BODILY INJURY(Per accident) $ ALL O SCHEDULED AUTOSS -- AUTOS N/A NON-OWNED PROPERTY DAMAGE $ (Per accident)HIRED AUTOS _ AUTOS $ EACH OCCURRENCE $ UMIBRELIALIAB _ OCCUR EXCESS LIMB CLAIMS-MADE N/A AGGREGATE $ DED I I RETENTION$ $ X I STATUTE I ER WORKERS COMPENSATION AND EMPLOYERS'LIABILITY Y I N E.L.EACH ACCIDENT $ 500,000 ANYPROPRIETOR/PARTNERIEXECUTIVE I WAI WA NIA 6S62UB8H08580922 05/10/2022 05/10/2023 A atEREXCLUDED? E.L.DISEASE-EA EMPLOYEE $ 500,000 (MandatoryMEM in N NH) It yes, IP11Oe 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 Truro 24 Town Hall Road AUTHORIZED REPRESENTATIVE 'Th Cv;-f MA 02666 w Truro Daniel M.Crovrey,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