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HomeMy WebLinkAboutBLD-23-003422' C a,114 )211 i 1 L1 Office Use Only � Penn k. s„i,vr c j®® i W O `-7•1 ; ,� Amount ''".� ti",, " Permit expires 180 days from L issue date 8LD-- 23--60 3 42z_ EXPRESS BUILDING PERMIT APPLIC . k TOWN OF YARMOUTH R E C.E 1 V E '� Yarmouth Building Department 2022 1146 Route 28 DEC w South Yarmouth,MA 02664 S08j 398-2231 Ext. 1261 LBulLD�tG DEPARTMENT CONSTRUCTION ADDRESS: 14 LoD N W 004 4-ki q " f IA, ASSESSOR'S INFORMATION: Map: � Parcel: OWNER:c�Pt ► ((6 \ L.C. ��A-Nv0004 • Poa NAME PRESENT ADDRESS' EL. # CONTRACTOR: 'l 7:::'(---k—'—f P-c)3C-iAac:,-- Ci3 . ......kAAN)‘:,.. ,,,z, ki,,,„,,,..,.,T,v,„„ NAME MAILING ADDRESS ' TEL.# '' e. t it esidential °Commercial Est.Cost of Construction$ 1 COD Home Improvement Contractor Lic.# 12( 61 Construction Supervisor Lic.# n g Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor 0 I have Worker's Compensation Insurance p y# �%;-L;a` 1 t .r ^14-C Insurance Company Name: 4CJ ����- Worker's Com .Folic WORK TO BE PERFORMED TentEj, Duration (Fire Retardant Certificate attached?) Wood Stove 0 Siding: #of Squares Replacement windows:# 3 5 1U 7s Replacement doors: # Roofing:ifit of Squares (Er)Remove existing* (max.2 layers) Insulation n FrOld Kings Highway/Historic Dist. J Replacing like for like Pool fencing i l 45 RP*11-0-1/4I ap ahi iw 4 ' 4t.-4 a,r •. a��X *The ns ► e rsposed of at `� Location of Facility 1 declare under penalties of perjury that the statements•e0rein 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 -,I Iffk- ocation of m d for prosecution under M.G.L.Ch.268,Section 1. Applicant's Sigitatur•• : d." , L Date: 12 a Owners Signature(or. ,achmen) "' A. Date: fj Date: ! v' ' 2'— Approved By: Building Official(or. . ee) EMAIL ADDRESS / Zoning District: Historical District: Yes No Flood Plain Zone: _ Yes No Water Resource Protection District: Within 100 ft.of Wetlands: Yes No Yes _ No �- (9(vn/2Z//u(i-P aGiie o ./ga,i C?iclacJ-e 1 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 �/ f/Office of Consume/Affairs8Bu ness��L�gu,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 06113/2023 WOO Washington Street -Suite 710 Boston,MA 02118 OLIVER KELLY OLIVER M.KELLY i� - 8 RHINE RD. t Not valid without signet re YARMOUTHPORT,MA 02675 Undersecretary Commonwealth of Massachusetts \ Division of Professional Licensure Board of Building Regulations and Standards Constructiotr'r3 pervfspr Specialty CSSL-099167 EEcpires:09/28/2023 OLIVER M KELLY s f 8 RHINE ROAD YARMOUTH P9RT MA:026T5 n ., .l Commissioner dua fi. UCmcfta.. • Aco CERTIFICATE OF LIABILITY INSURANCE DATE(MWDD/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 PHONEINC. .Fxtl: (508)775 1620 FAX (A/C, E-MAIL ADDRESS: I S U I I I V a n @d O i n S.CO m 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 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 ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE INSD Wvn POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYYI 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 LIABILITY (Ea accident) BODILY INJURY(Per person) $ _ ANY AUTO _ ALL OWNED SCHEDULED N/A BODILY INJURY(Per accident) $ AUTOS — AUTOSPROPERTY DAMAGE NON-OWNED (Per accident) $ HIRED AUTOS AUTOS $ UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ WORKERS COMPENSATION X STATUTE OTH- ER AND EMPLOYERS'LIABILITY YIN E.L.EACH ACCIDENT $ 500,000 /M ANYPROPRIETOR/PARTNER/EXECUTIVE A OFFICEREMBEREXCLUDED? N/A NIA N/A 6S62UB8H08580922 05/10/2022 05/10/2023 E.L.DISEASE-EA EMPLOYEE $ 500,000 (Mandatory in NH) If 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) dorsement WC 20 03 ,no authorization is claims for enefits to employees in Istate be s ofd her than Massachusettsachusetts employees the insured hies,or h snh hired those employees o6utside of Massachusetts.given 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 Daniel .Cr y,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 of Industrial Accidents -'1 --J Office of Investigations i , i— - Lafayette City Center ,3! ,. 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): E 441 ' Le— Address:Address: . E. LAO City/State/Zip: D `~ 02-06 Phone#: 5o is 5006. 4640 Are you an employer?Check the appropriate box: 4. �, am a general contract d Ior an Type of project(required): 1.t�1 I am a employer with +1 ❑ I e l g 6. Q 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. Q Remodeling ship and have no employees These sub-contractors have 8. Q Demolition working for me in any capacity. employees and have workers' 9. Q Building addition [No workers' comp.insurance comp.insurance; required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions _ 3.El officers have exercised their I am a homeowner doing all work 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.ErRoof 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'con.p.miion 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 employee& Below is the policy and job site information. t Insurance Company Name: Ij CLbk-MaelliCAO Policy#or Self-ins.Lie.#: €6 C)be614,0`5.5‘60q 2. , Expiration Date:-6 o(0'2.025 Job Site Address:N 4 N OC-W OGity/State/Zip:�� 1��t/P G� f1+- 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 Sianature:e , . 3 Date: '2 l I 1 2 1 t I Phone#: 50S 50 ti tibtiO 1 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): 1❑Board of Health 20 Building Department 3i3City/Town Clerk 4.12Ft1`ectrical Inspector 5D lwmbing Inspector 6.0Other Contact Person: Phone#: u44 3aw4 • ammo Asa jugham,_ • SIR IRO;ire � • '�,4,} dam x % r 4s • .0100111000110‘01011001411111114100 '%E''� { .. k�§, • • yy fit 101011/611rr 11011111. �', 011111 ell.00011110 y 711111/ i t *5 qs r „,,`h 3-1 anv' o- r i Rin p y Sb �a 'X 11' y .4, x:T{ i1 4 h,r" y '� v A�;k Y ak � '- . i xp ; u x TOWN OF YARMOUTH *d e- 1146 ROUTE 28, SOUTH YARMOUTH, MA 02664-4451 Telephone(508)398-2231 Ext. 1292-Fax(508)398-0836 I • OLD, KING'S HIGHWAY HISTORIC DISTRICT COM :2- 5 20`b F V E D APPLICATION FOR I KNG' HP3R,P,'Ikt_j CERTIFICATE OF EXEMPTION DEC i 6 2022 Application is hereby made for the issuance of a Certificate of Exemption under Sections 6 a icf37i IdiirCrhgrrit*rP4\70 Or_N1 Acts of 1973, as amended, for the proposed work as described below and on plans, dray accompanying accompanying this application. Type or print legibly: Address of proposed work: /14 LOCq /2 4 NA)0 CO L't Pe ezr Map/Lot# I L q 71 Owner(s): .0 ‘Sig-r-1 Phone#: 77 Li (*a-36 6 3 35 All applications must be submitted by owax;or accompanied by letter from owner approving submittal of application. Mailing address:kt-\ LocQAOc -140.A400-rk% tkAA 01101 Year built: ICV40 Email: ti CANNACA el-• ki€21— Preferred notification method: Phone Email Agent/Contractor: a...We(2.. 11.-iaLL1 Phone#: Mailing Address:5S Lk.k.)... 15 ; 111:4a.„114 OLTR4 02_61 Email: OCr & I cLQD COM Preferred notification method: El Phone Email Description of Proposed Work(Additional panes may be attached if necessary): )1/4‘ "rt.tJer GA.A4 2„ <A b GU. 'er.0-0C 1/31.11-1 LAO bev1A-a-kk,„ °Z;Acie... Polocto,)&i) QC)(-09_ Qse-A-p_ (A- .()DeQ 1;,)1(TtA cloa UWE ji,LL1X, 61\11:T3 Signed(Owner or agent): el Date 2- ' 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: Ptil 51202' Approved Approved with changes ; Amount PIA Reason for denial: CashiCk#: V I Rovd by: Li.5. Date Signed: 9i151? Signed: 5, eft-et:W e APPLICATION#: t5 01 V5 2017