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HomeMy WebLinkAboutBLD-23-003422 C ai t t71- 12 JZi I Z2_ Office Use Only o1Y.: r.,},, �O� Permit# Amount l . „. :s. c,..;,.' Permit expires 180 days from i►S issue date 6LD-- 23--OD 342a EXPRESS BUILDING PERMIT APPLIC A $ k TOWN OF YARMOUTH RECEIVED . _ Yarmouth Building Department �ZZ 1146 Route 28 DEC South Yarmouth,MA 02664 508) 398-2231 Ext. 1261 BUR DiNc DEPARTMENT q, 0 ,3,CONSTRUCTION ADDRESS: 14 N C,,G., 3 PI ASSESSOR'S INFORMATION: Map: Parcel: � A09..4,10 OWNER: l( \ 00,( t)Pt-"' Nt Poac- NAME PRESENT ADDRESS TEL. # CONTRACTOR: II''i-'I--'`"{ e-0 f--i/ (. i to,.J;;e.. , a-S—ri_m.:kz,.)Ti )r.' 4 A \ uL i i c NAME MAILING ADDRESS  TEL.#, .,, 0( ti b 4 f, OResidential OCommercial Est.Cost of Construction$ 2 Home Improvement Contractor Lic.# l d Construction Supervisor Lic.# I I / Workman's Compensation Insurance: (check one) O I am the homeownerfj� 0 I am the sole proprietor I have Worker's Compensation Insurance }I 4\ tL4IWorker's Com Poli o14Insurance Company Name: _t1p. y# WORK TO BE PERFORMED Tent Li Duration (Fire Retardant Certificate attached?) Wood Stove El Siding: #of Squares Replacement windows:# 3 5aLIUG447.5 Replacement doors: # � Roofing:vi#of Squares (" 1 ( l)Remove existing*(max.2 layers) Insulation Fr1 Old Kings Highway/Historic Dist. cp Replacing like for like Pool fencing ( t 4��S A_)) BOA, D 5Thelhris l!e7lisp ed of at: 1_44-44-c:'-rral ' J-."-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 'Allocation ofia• •. d for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature � Date: 12 if a / 22 Owners Signature(or: tachmcn) ' Date: Approved By: Date: / — 'el---2_,.._ Building Official(or. _ cc) EMAIL ADDRESS: / Zoning District: Historical District: Yes No Flood Plain Zone: '.1 Yes _- No Water Resource Protection District: Within 100 ft.of Wetlands: Yes No -! Yes No 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 �/ L /�Office�of Consumer/Affafirs 8 Bus ness'Iid uiStion 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 f 000 Washington Street -Suite 710 Boston,MA 02118 OLIVER KELLY OLIVER M.KELLY 8 RHINE RD. /214104: YARMOUTHPORT,MA 02675 Not valid without signet re Undersecretary Commonwealth of Massachusetts {�r Division of Professional Licensure • Board of Building Regulations and Standards Constructieir"3 pi� lwpr Specialty • CSSL-099167 i E- pires:09/28/2023 OLIVER M KELLY 1,. 1, 8 RHINE ROAD YARMOUTH PORT MA'02675 o Commissioner 011ie f;. tj(.imtNln ACG 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 CONTACTNAME: Linda Sullivan DOWLING &O'NEIL INSURANCE AGENCY PHON(A/ No.Extl: (508)775-1620 FAX (A/C, AMAIL DDRESS: 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 INSURER E: 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 ADDL SUER POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE MD WVD POLICY NUMBER (MM/DD/YYYY1 (MM/DD/YYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE 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: COMBINED SINGLE LIMIT $ AUTOMOBILE LU\BILITY (Ea accident) BODILY INJURY(Per person) $ _ ANY AUTO _ ALL OWNED SCHEDULED N/A BODILY INJURY(Per accident) $ NAUTOS AUTOS N/A PROPERTY DAMAGE $ HIRED AUTOS AUTOS AUTOS (Per accident) — $ UMBRELLA UAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ WORKERS COMPENSATION X STATUTE ERH AND EMPLOYERS'UABIUTY YIN E.L.EACH ACCIDENT $ 500,000 AFFICER/M MBER EXCLUDED/ /DXECUTIVE WA N/A NIA 6S62UB8H08580922 05/10/2022 05/10/2023 A (Mandatory in E.L.DISEASE-EA EMPLOYEE $ 500,000 (Mandatory in NH) If yes,describe under E.L.DISEASE-POLICY LIMIT $ 500,000DESCRIPTION OF OPERATIONS below N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) uant to dorsement WC 20 03 06 ,no claims for ens is to employees in will be otherfd than Massachusetts Massachusetts if the insured ees hires,or hasnh hired those employees outside of Massachusetts. on is This 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.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 Barnstable 200 Main Street AUTHORIZED REPRESENTATIVE Hyannis MA 02601 n ( (A)Daniel M.CroVey,CPCU,Vice President—Residual Market—WCRIBMA I ©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 of Industrial Accidents Office of Investigations 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 Please Print Legibly Name(Business/organization/lndividual): 'g"1 � Le. Address:46 raiur.3 City/State/Zip: # .1 0: OWS Phone#: 30 509i 46410 Are you an employer?Check the appropriate box: Type of project(required): 1.El I am a employer with a 4. 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 5. Q Demolition working for me in any capacity. employees and have workers' 9. El Building addition [No workers' comp.insurance comp.insurance.* required.] 5. [l 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 12.1iiRoof 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. Iam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: iCoi Policy#or Self-ins.Lic.#: €M .O 64261 ,046.%04 2.2. Expiration Date:.6 a(0'2-023 Job Site Address:[ ( I_CC.../ 2ti,)N OC-11/ •OCity/State/Zip: (�.G` / . 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 and the pains and penalties of perjury that the information provided above is true andQcorrect. Signature:0, � � Date: 2 4 17 / 2'L .. l 1 11 phone#: 5045 5 tiJ 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 3.JCity/Town Clerk 4.QEfech ical Inspector 5Ek lambing Inspector 6.DOther Contact Person: Phone#: f 1 y �� OL . -.0a•-.-4.4-m;!--glikw."4:0-,,,-.---•:. .. iii 01141L-0111111PFTAtigik,;:33014-..:::..-;. „. � y 1 ( r 'a .-1,:1-ir*lfr7 likO'ii'..:,.--:--AC4-Zt -..-• :. '' .••:.-7-' ::--•• � � �` s '� 17*, ,te e .•, fi-- .,, ' u f x n' .£.{ .„. .. o..r:_.," > .. 1, ` , v %rk'' 11,- 1 w v n s:e::;01P Mgt x ti � X 2 Ift visismo. • t- <3 Tpli .. i,`. ry k '- it G ,,-, - • .,..,.,,,,,,,-f..::,,,,f,,::.,4:1,!;-;;;:::;;;;;:::,,,._:„•:„.....:•::,..;:t.:•:;-;;,',-;.:-:- , ..',,- y Rr -&. u "s �,. t SYt� ' N fr ,, ^ 5 ^Sa- x"53n44., i r3 f+J i 4'b - d ti lr .fi #- *, fi �5 -✓.0 pad;'- a k£' �x i i, .r%J ' �i�'nS`-� t •li. x a . , • TOWN OF YARMOUTH 4..4- 44 1146 ROUTE 28, SOUTH YARMOUTH, MA 02664-4451 I - I ' •i Telephone(508)398-2231 E . 1292-Fax(508)398-0836 QL• KING'S HIGHWAY HISTORIC DISTRICT COM /.,027 E1VED , li-0-4iva-lk) 1 APPLICATION FOR ' ow KiNn'S}-0'.3HVVAY-1 CERTIFICATE OF EXEMPTION DEC i 6 2022 Application is hereby made for the issuance of a Certificate of Exemption under Sections 6 a cf3Ti lifreWitittir1-4,701 ME N1 Acts of 1973, as amended, for the proposed work as described below and on plans, dra accompanying this application. Type or print!edible; Address of proposed work: 114 LO C i'/ 124(")0 C41 ti, 190/21- Map/Lot# Ial q *71 Owner(s): P,_ ->Okt`..) tA.00ZA 1 Phone* 7714 C5"363 6355 Ail applications must be submitted by owwr accompanied by letter from owner approving submittal of application. Mailing address:atA k-acq 9...AN)NYOCAA 1 -OM ocint(>0Q.7 OM 02-61S- Year built: ICk440 Email: C. 1)n 1 @....eavkcA er. OE:1— Preferred notification method. Phone 7- Email AuentiContractor: 01-1.4.e.a iki.ui Phone#: Mailing Address:% LA r0, ... Q0/412) " cut W'rik VfOiLS-- IAA 02-61 Email:t&t,t.,‘'t 0 Of-‘.NI.G-0.-k..C-x..4;;;X.A.D. ., COM Preferred notification method: El Phone 17 Email Description of Proposed Work Additional panes may be attached if necessary): C-x. T,'t Wo- t-IGIA GAAM :2) <AZ) '9A tx-*G U. .4.4:4 td3Crti 1- Mn-a— 1400.E c)t9,k,A,A,t,,,,c SA,1/4„N C.)-k. UOir- 1 Qtti_ PolOcto,),,,b QADL,O(Z, Q-eckArtz ,.7„, c_Nkss-ck.036, Signed(Owner or agent); .... ,_—/ ILO- .-... Date- 0-(LI' 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 2)1 510" VI Approved __Approved with changes . n ,,,,r-,, Amount tv4 Reason for denial: ' ' CashICK#: NA 19 Rcvd by: Date Signed: 91151?3 Signed: . "e t?AtetoTh1/4(ld APPLICATION#:(92--E15 i 01 V52017