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Home My WebLink AboutBLD-23-001813 Q r---" Office Use Only 1pl� l � k:io ��++T Hermit# O i '. //y• ®l.l rJ 2�22 Amount .D� t .wrr n cs/4., J `aw,,,ta+� ' Permit expires 180 days from .:;. ::= BUILDING DEPARTMENT issue date 1 OLD-u2 3-601V/3 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 3998-2231 Ext,112611 2 CONSTRUCTION ADDRESS: " 'Q"A�` c `L W✓ 1 .8u1-t/( ASSESSOR'S INFORMATION: Map: Parcel: nn OWNER ASTA 'IAV SZP+.►� `a bi.LiSl-r:l Lt W tSC. AS? " 14 QV 1013 NAME PRESENT ADDRESS TEL. 31:.(o &al ci 769 r CONTRACTOR: 'LA-'-^f `,. C--J'J(2,...- `6 ZkAk:,:if::. k .A.-ri.:v '";1.,,_?,r e' LA3`'� 02.k5 c NAME - MAILING ADDRESS ' TEL.I'=<� Q, "'„ 4 ; , 0 Residential 0 Commercial Est.Cost of Construction$ I.0,Sc O LL�� Home Improvement Contractor Lic.# 12 `"i- Construction Supervisor Lic.#at t 1 ` Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor III have Worker's Compensation insurance A Insurance Company Name: -4 '1(' .f�.s,i Worker's Comp.Policy# t.'~ice e 3'� 12 Z. WORK TO BE PERFORMED Tent ,L1 Duration (Fire Retardant Certificate attached?) Wood Stove Q Siding: #.of Squares Replacement windows:# Replacement doors: # Roofing:tj#of Squares II ([3 Remove existing*(max.2 layers) Insulation 1 f Old Kings Highway/Historic Dist. CT Replacing like for like Pool fencing { 1 *The debris will be disposed of at: 1 Location of Facility I declare under penalties of perjury that the statements herein contained are true and correct to the best of my Imowledge and belief. I understand that any false answer(s) will be just cause for denial ora revocationoc of my license and for prosecution under M.G.L.Ch,268,Section 1. Applicant's Signature: (tom � L-�� Date: l'0 / 6 / 22. Owners Signature(or attachment) Date: Approved By: G? (J2--;.. Date: /er-6 2 Building Official(or gne EMAIL ADDRES Zoning District: Historical District: Yes No Flood Plain Zone: `_- Yes I. No Water Resource Protection District: Within 100 ft.of Wetlands: Yes No Yes = No The Commonwealth of Massachusetts Department of IndustrialAccidents t',r y _ Office of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston,MA 02111-1750 FZ* www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information �[ �O Please Print Legibly Name (Business/Organization/Individual): 14 U Ot V s C-- Address:Ct5 t LIAO City/State/Zip:'jMMDJYt(AOLt OWS Phone#: 5o i Soot 4b40 Are jou an employer?Check the appropriate box: Type of project(required): 1.1011 am a employer with { 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. 0 New construction 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 8. ❑Demolition working for me in any capacity. employees and have workers' 9. El Building addition [No workers' comp. insurance comp. insurance.: 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.❑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'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: A. Policy#or Self-ins.Lic.#: 656'z0 e:P61.01.o16StOq 22 Expiration Date:.6-{O•2 2 3 Job Site Address: 2. ‘4•42As-r P • City/State/Zip: W- '44&o��`l 44- b?3 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify and i the pains and penalties of perjury that the information provided above Lstrue and correct. Signatu re:A. I I' Date: I 5 22_ Phone#: So$ e t'1,WO 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): 10Board of Health 20 Building Department 31:City/Town Clerk 4.0 Electrical Inspector 5E'lumbing Inspector 6.DOther Contact Person: Phone#: KELLY ROOFING PH. 508 509 4640 8 Rhine Road MA C.S.L. 1099167 Yarmouthport MA H.I.C.R. # 128957 MA 02675 September 30'2022 Proposal submitted to Chastaty Murphy of 2 Kristen Path, 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 Ice and Water damage protection membrane to be installed on first Six feet of all eaves and around all protrusions. Remainder of roof deck to be covered with synthetic undertayment. Install limited lifetime warranty Architect style Shingles, color to be specified, All shingles to be storm nailed (6) Replace plumbing vent pipe boots with new. Repair/Replace all flashings as necessary including Chimney. Install Certainteed Filtered ridge vent with hand nailed caps. Complete Clean up off all areas including all gutters and all nails after project complete At a total cost of$10,500 For Shed Roof Add$450 Payment Schedule; Balance upon Completion Proposal Submitted by: Oliver Kelly-- Proposal accepted by:C Date./0 /03 /2022 This proposal is valid for 30 days from date above, please call to verify thereafter. BEST CONTACT PHONE NUMBER: 210 - totot -ZV� AC® 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(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). PRODUCER wale Linda Sullivan DOWLING&O'NEIL INSURANCE AGENCY me,ray (508)775-1620 I tea. E- MAIL A Sullivan doins.com ADD 973 IYANNOUGH RD INSURERS)AFFORDING COVERAGE NAIL# HYANNIS MA 02601 INSURER A: ACE AMERICAN INSURANCE CO 22667 INSURED INSURER B: KELLY ROOFING INC INSURERC: INSURER D 8 RHINE RD INSURERS: 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 POUCIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IN SR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP INSD wvD POLICY NUMBER (MM ODIYYYY) (MM/DD/YYYY) LIMITS f COMMERCULLGENERALLABILITY EACH OCCURRENCE $ CLAIMS MADE OCCUR DAMAGE TO REN I ED PREMISES(Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL BADV INJURY $ GEM.AGGREGATE OMIT APPLIES PER: - GENERAL AGGREGATE $ POLICY JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY J COMBINED SINGLE LIMIT $ /Ea accident) — ANY AUTO BODILY INJURY(Per person) $ ALL OWNED —SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per accident) $ HIRED AUTOS NENON-OWNED PROPERTY DAMAGE OS (Per accident) $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE N/A AGGREGATE S DED J J RETENTiONS WORKERS COMPENSATIONNA. S AND EMPLOYERS'LIABILITY Y I N ANYPROPRIETOR/PARTNERIEXECUTIVE X I STATUTE ER A OFFICER/MEMBEREXCLUDED? NIA NIA WA 6S62UB8H08580922 05/10/2022 05/10/2023 EL EACH ACCIDENT $ 500,000 (Mandatory in NH) 0 Y�describe E L DISEASE=EA EMPLOYEE $ 500,000 DESCRIPTION OF OPERATIONS belay EL DISEASE-POLICY LIMIT $ 500,000 N/A ( I I ! DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached S 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 1 THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN • Ke1f2/2f/2CCte6die P-/ 'CG4.-00f? G L • 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 grr Kiriibwivaptvz/%16(is iirr� f'/ZL Office of Consumer A rs business rdwgui Lion 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 06f1312023 f000 Washington Street -Suite 710 OLIVER KELLY , Boston,MA 02118 OLIVER M.KELLY , Oa> 4 0018 RHINE RD. lioo `a•i.:/YARMOUTHPORT,MA 02675 Not valid without signatire Undersecretary Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Constructfeiyglip li6p.r Specialty CSSL-099167cpires:09/28/2023 OLIVER M KELLY . • 8 RHINE ROAD YARMOUTHART MA-> 3 tfi1S1•l:lll'\� Commissioner J'ut A u nto+ .