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HomeMy WebLinkAboutUntitled C ti Jzlzi IZ2_ Office Use Only oF'XRR evii/wL y,�« � � �CA Permit# p ,(\\‘.,, Amount j OD.6 V' w..tr" n .,. i Permit expires 180 days from issue date 6LiD-- 23 403422_ EXPRESS BUILDING PERMIT APPLIC TOWN OF YARMOUTH RECEIVED _ Yarmouth Building Department 1146 Route 28 DEC 2 0 2022 South Yarmouth, MA 02664L 508) Nr�398-2231 Ext. 1261 aui� vU DEPARTMENT CONSTRUCTION ADDRESS: 14Loc)ko t - ,o-ix' ASSESSOR'S INFORMATION: Map: Parcel: OWNER:c7� A09--kAal ((�6 \ D A- 00i (I • 1)0f2 -i NAME PRESENT ADDRESS L. # CONTRACTOR: if"i-A-',f 0 f ifs)G Cr3 .tie;k-:i',d. LO- *-1131A-C-',.%)"s iA"b-- A 02_1 1 NAME MAILING ADDRESS ' TEL.#5c, F r# t{ b 4 E t Residential °Commercial Est.Cost of Construction$ 1 OO Home Improvement Contractor Lic.# 12 6u! Construction Supervisor Lic.#05(1° 67 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: 4c 4 CAN Worker's Comp.Policy# may`'Se3'��i 27, ttt WORK TO BE PERFORMED Tent II Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# 3 5.14114405 Replacement doors: # Roofing:/#of Squares (� l�!)Remove existing*(max.2 layers) Insulation n . 71 Old Kings Highway/Historic Dist. a)Replacing like for like Pool fencing I l 45r/O, *The rrs1Wi lie3lisiiiiied of at: 44 P-4,4- --,'"t . t 4:14-'-'3f-j-c-1-- Location of Facility I declare under penalties of perjury that the statements+erein 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 de .1 F ocation of m ` . d for prosecution under M.G.L.Ch.268,Section 1. / q Applicant's Signa. .• _�o� , Date: {? / /t / 2 Owners Signature(or. tachmcn) ' Date: , Approved By: t' Date: / 3.*- �— Building Official(or s- cc) EMAIL ADDRESS:' Zoning District: Historical District: Yes No Flood Plain Zone: '= Yes =- No Water Resource Protection District: Within I00 ft.of Wetlands: Yes No I. Yes - No Y-Ze9c/22/2w7w/wage o//gcc.� Z e7 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 C 20M-05/17 �/ Office of/Consumer Affifirs 8 isus nesspt' ulation - 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 06f13/2023 feet/Washington Street -Suite 710 OLIVER KELLY Boston,MA 02118 OLIVER M.KELLY j, • 1�►� 8 RHINE RD. Not valid without signat�re YARMOUTHPORT,MA 02675 Undersecretary Commonwealth of Massachusetts ii� Division of Professional Licensure ' Board of Building Regulations and Standards Constructiotr'Stpig i65 r Specialty - CSSL-099167 E pires:09/28/2023 OLIVER M KELLY +,` 1, 8 RHINE ROAD . . YARMOUTH P.)RT MA (4675 )/SS.I:I�-V' Commissioner Olwea fi. UCrr,ci ttk- DATE(MM/DD/YYYY) Aco D 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 fA/C"No.ExH: (508)775-1620 FAX (A/C,No): E-MAIL ADDRESS: ISUllivan@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 INSURER C: 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. INSR TYPE OF INSURANCE ADDL SUER POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYYI COMMERCIAL GENERAL LIABILITY EACH OCCURRENCEDAMAGE 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 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 LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY X STATUTE OTH- ER Y/N 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 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If es,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 Town of Barnstable ACCORDANCE WITH THE POLICY PROVISIONS. 200 Main Street AUTHORIZED REPRESENTATIVE Hyannis MA 02601 Daniel Cray,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 The Commonwealth of Massachusetts Department oflndustrialAccidents '-'� Office of Investigations 1 ;: ��=: Lafayette City Center `� -:1'=:L =' 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 Name(Business/Organization/Individual): ig Q LC.4 Address: as3 City/State/Zip: MDJ 02-06 Phone#: .3o 5Oj 469,10 Are,,you an employer?Check the appropriate box: Type of project(required): 1.10 I am a employer with tit 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. El New construction listed on the attached sheet 7. ❑Remodeling 2.El I am a sole proprietor or partner- ship and have no employees These sub-contractors have S. ❑Demolition working for me in any capacity. employees and have workers' [No workers' comp.insurance comp.insurance.$ 9. Building addition required.] 5. [] 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.JRoofrepairs insurance required.]t c.152,§1(4),and we have no employees. [No workers' 13.E]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. tContractors 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. Ifthe sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employee& Below is the policy and job site information. Insurance Company Name: A ek-- tM Policy#or Self-ins.Lic.#: 66(02.0 °614,0155%0g 2.2 Expiration Date:.6 o(O'' -025 Job Site Address:N -04A)N( )ci9 .041r City/State/Zip:(Aomori./P 1r- /1 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 war the pains and penalties of perjury that the information provided above is true and correct Signature , 'Z (� Date: I7 I Phone#: Z 61 'Lit r II Official use only. Do not write in this area,to be completed by city or town officiaL t City or Town: Permit/License# . Issuing Authority(check one): 4 1DBoard of Health 20 Building Department 3DCity/ own Clerk 413Efectrical Inspector 5.0Plnmbing Inspector 6.DOther Contact Person: Phone#: p �� Wi +�i t .. $00.011.111011110 �� _�'e '�' ''* '''-'''', .',..' g•''''''''''.,,':'," ''.: ',:''''1....'''.'L-1-1f,-4 '''.t.?:` 'V'',';''APS.S''''''',;'''' . . ' 1 `fY4 0 ., ..,k;:y.':s�,w;ca'��d'v . w., a 'fit/' (:<:: y�_ ek,tr "; Xz r+ 4Y v. ;� �, x > � r t- z ��� g „s a ri >z r twos pepeoll Ilk p i Itliik R ail°ci"...".0.1„Tils ., p r4 ,,,,,,,,,,,,,,. :,,_:H_.. ._,•• �a} ...,...,,•,, a ..S rsk �' t z. � $tom„ . , TOWN OF YARMOUTH 1146 ROUTE 28, SOUTH YARMOUTH, MA 02664-4451 : a . I ,, °: -4 Telephone(508)398-2231 Ext. 1292-Fax(508)398-0836 ' OL a KING'S HIGHWAY HISTORIC DISTRICT COM E1VED ,. .. APPLICATION FOR CERTIFICATE OF EXEMPTION DEC i 6 2022 Application is hereby made for the issuance of a Certificate of Exemption under Sections 6 a c 7J birititi5ittkre410 bliE Ni Acts of 1973, as amended, for the proposed work as described below and on plans, drav n9wr phtwgraphw .-- accompanying this application. Type or print healblv; Address of proposed work: 14 LO c f d 12 4 ry 10 0 c44 Lt Po gi Map/Lot# I q 7 i owner(s): -<ipa._ ,,,,,,, 04.‹) tik.0Q.1A.Q.:(1 Phone#: 774 Ail applications must be submitted by ownwr accompanied by letter from owner approving submittal of application. Mailing address:tt\ L004 9-A cm- .LI4am 00-1\I PO Q7 titAA 02121T Year built: 1°050 Email: C t 11 I @.--CO/MCA 'e'r• ksICT— Preferred notification method: Phone 7 Email AcienttContractor: LI JZ:a. ikjul Phone#: Mailing Address:% ,AA4.10T, AO t kii iNali4 WA-11,Cbl?...,S- t AA 02 61 S Email:kba.k.-ki 9-0 0C-k t\lra-o-kr...A.00D ., COM Preferred notification method: r Phone 11 Email Description of Proposed Work(Additional panes may be attached if necessarvi;, c6.% c...kIrtt.,›Co• Li G 4-; GAA 4 koz3C t/3t.Ttl 14\t..)ClevtAil.)./ 14014,* &Au.... Ot.k.ikt,_,,c AN GA.Z. ct.Car- i Qa_i_. Polo rto,)&i.) QoLca., Qe9„,6,ez 2) CAks-ftws ‹.-tk.A.c.,vs:Is it‘) ..'estg-o_ O (&,(1.-i-,1-( L.«)t I Li LAY-i... cop (-4 tki kii,,,LUX Ots.1 CC...3 Signed(Owner or agent): 00C->_, il, 0 Q(,: Date- 12 A' 22- ). Owner/contractor/agent is aware that a permit may be required from the Building Department.(Check other departments,also.) This certificate is good for one year from approval date or upon date of expiration of Building Permit,whichever date shall be later. For Committee use only: Date: i;/I 51201 V Approved Approved with changes ,A P iii 1 Amount tvA Reason for denial: 1 _, ''''Cash/Ck#: /V/4 : Rcvd by: Date Signed: Pi 15-W Signed: '. ceVKDO 011?1 ‘ APPLICATION#:0"--E15 I 061 V5 201 7