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Home My WebLink AboutBLD-23-001812 ; RECEIVED LA�"O� R Office Use Only � t;y' 4 j1 I� I b�. OCT 2022 Pemtit# 11. Amount "' a- BUILDING DEPARTMENT "fa ' sy — Permit expires 180 days from issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 2-k( c'IL).---Pt-sewc-- 3 — &0 . 4.4.w.A.03_11 ASSESSOR'S INFORMATION: Map: Parcel: OWNER( t 0 f .vCeil_ 2 V cle-ecsA-N c ST. % . 14,N.Q.A .OJ'Ttl VIA 0,a6 Q9 NAME PRESENT ADDRESS TEL. ii2.03 Cl t$ 4 SSZ r CONTRACTOR: , %t-A,-°s.,j '-)0C--atj G. .i.\e a+J:,�. ; . .�U+J tk IAA 02.ki 1 C NAME MAILING ADDRESS TEL.#51.z.g �o t{ 6. k c OResidential 0 Commercial Est.Cost of Construction$ 16 tci00 Home Improvement Contractor Lic.# .. — i Construction Supervisor Lic.#Olt_Y ' 67 Workman's Compensation Insurance: (check one) 0 I am the homeowner l] I am the sole proprietor p I have Worker's Compensation Insurance Insurance Company Name: LC 4VU\ Worker's Comp.Policy#b 6tzi-0 r-sluo S R WORK TO BE PERFORMED Tent El Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing:tl#of Squares ( -. )Remove existing*(max.2 layers) '� � g Y ) Insulation 11 (� l 1 Old Kings Highway/Historic Dist. Replacing like for like Pool fencing n *The debris will be disposed of at: q A -+-+. '�"1 '-,;.-i 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 answer(s) will be just cause for denial or revocation of my license and for prosecution under M.G-L.Ch.268,Section 1. Applicant's Signatur \ 10 Date: / 2 2- Owners Signature(or attachment) Date: Approved By: B , . ' Date: — /'" uildina Official " esi� } EMAIL ADD Zoning District: Historical District: Yes No Flood Plain Zone: Yes _ No Water Resource Protection District: Within 100 ft.of Wetlands: Yes No Yes No AC DATE(MWDDNYYY) 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 POUCIES 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 CONTAN CT Linda Sullivan DOWLING&O'NEIL INSURANCE AGENCY PHONEtic„F (508)775-1620 FAX (A/C,Nog ADon : Iullivan@doins.com 973 IYANNOUGH RD INSURER(S)AFFORDING COVERAGE NAM* 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: 775628 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. EXP LTR TYPE OF INSURANCE y ADDLEliy� M POLICY NUMBER ,I POJWYYYYY) (MMMIDEFF PO�D/YYYY) LIMBS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCEAGE 1 $ RtNTED CLAIMS-MADE OCCUR PR MI ES(Ea ocarrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GENT AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ POLICY JEI�CT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE UABIUTY COMBINED SINGLE LIMIT (Ea accident) ANY AUTO BODILY INJURY(Per person) $ —ALL OMMED SCHEDULED AUTOS N/A BODILY INJURY(Per accident) $ AUTOS NOON-OWNED PROPERTY DAMAGE _ HIRED AUTOS — AUTOS (Per accident) $ • UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X PTARTUTE ER AND EMPLOYERS'LIABILITY ANYPROPRIETORIPARTNERIEXECUTIVE Y!N EL EACH ACCIDENT $ 500,000 A OFFICERIMEMBEREXCLUDED? N!a wa WA 6S62UB8H08580922 05/10/2022 05/10/2023 (Mandatory in NH) E.L DISEASE-EACMPLOYEE $ 500,000 N describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS I 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-compensationflnvestigationsl. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL •BE DELIVERED IN Town of LakevilleACCORDANCE WITH THE POLICY PROVISIONS. 346 Bedford Street AUTHORIZED REPRESENTATIVE Lakeville MA 02347 Daniel M.Crowley,CPCU,Vice President—Residual Market—WCRIBMA ®1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD KELLY ROOFING PH. 508 509 4640 8 Rhine Road MA C.S.L.#099167 Yarmouthport MA H.I.C.R. # 128957 MA 02675 INSURED September 6, 2022 Proposal submitted to Mr. David Parker of 211 Pleasant Street, South Yarmouth MA. We propose to supply all materials and labor required to remove and replace the existing asphalt roof on the house at the address above. Protect all walls,Windows, shrubs, plants etc. during roof strip. All debris to be removed to town transfer. Install 8"White Aluminum Drip Edge on all Eaves, 5"White Drip Edge to be installed 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 To be Covered With Synthetic Roof Underlayment. Install limited lifetime warranty Landmark Architect style Shingles, color to be Specified. All shingles to be storm nailed (6)We Generally Use Certainteed Products with All Accessories to maximize available warranties. This proposal is based on their Limited Lifetime Warranty Landmark Series Shingle Replace plumbing vent pipe boots with new, Repair/Replace all flashings as Necessary. Install Certainteed Filtered Ridge Vent with hand nailed caps. Complete Clean up off all areas including all gutters-and-all-nails after project complete. Obtaining of Town Building Permit. At a total cost of$15,900 , ,- . --P lobe 0.w vile For Landmark Pro Shingles Add $750 , --lc,/ auc,.,,p ,,. ` /)//s i ,j --- - ,t h-tc r cl C ( r Ni Payment Schedule; Balance upon Completion Proposal Submitted by: Oliver Kelly - (---- ' /) Proposal accepted by, ‘,,, , } I Date. , / /2022 A " -- 13— m AsiL 3 / '' , ;)... . . The Commonwealth of Massachusetts 7 it , —pi, Department oflndustrialAccidents ,: — l Ca/egress Street,Suite ZOO e 14le Boston, MA 02114-2017 �' „� _ www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly n Name(BusirresslOrg:,*.:.'. dtviduat): -'.G 1-1-4 KcCJ A rejt t' .:; 2 9) Address: �; � • - City/State/Zip:1 -M,3-J 6APO-04 1"4 0 Ph ne#: O 9. `'t b t • Are you an employer?Check the appropriate box: Type of project(required): 1.271 am a employer with ( employees(full and/or part-time).* 7. C New construction 2.12 I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 3.0I am a homeowner doing all work myself. 9. 0 Demolition y [No workers'comp.insurance required.]t 4.❑I am a homeowner and will be hiring contractors to conduct all work on myproperty. 10 Building addition I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors With no employees. - 12.[l Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet These sub-contractors have employees and have workers'comp.insurance.: 13_roof repairs 6.0 We are a corporation and its officers have exercised their rightof exemption 14.❑Other p per MGL c. 152,§1(4),and we have no employees.[No workers'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 contractois must subraite new affidavit indic.atirrg sack #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 pro 'ding workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: �,. .i ,,IIAC, Policy#or Self-ins.Lic. #: (5 i.{ '3'7 L—C..Ex ' 5 "�� ptration Date: ' Job Site Address: -'1 i,F pc S atJ'- City/State/Zip SS 2w6,Q. i1(k t17)bbc; Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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 S250.00 a day against the violator.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. , Sianaiure0_ W34. Date: ` (0 / s / Phone#: SO`-6 ;_ '`JI 46440. ( 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 (circle one): 1.Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: • L o/22.w61/4epe ridlD/./'Rac,i. Gry?4CGc/'-Pi G.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 0 20M-05/17 ,f �ce of Consumer Affairs business negur�tion 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 06f13f2023 1000 Washington Street -Suite 710 Boston,MA 02118 OLIVER KELLY, OLIVER M.KELLY QC2-C2'8 RHINE RD. a YARMOUTHPORT,MA 02675 Not valid without signature Undersecretary Commonwealth of Massachusetts rOf Division of Professional Licensure Board of Building Regulations and Standards Constructie0ouperViGpr Specialty CSSL-099167 • cpires:09/28/2023 OLIVER M KELLY , + 8 RHINE ROAD YARMOUTH i9RT Mk +2675 Commissioner diaA I%. Udrad .. ,::