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Home My WebLink AboutBLD-22-007280 (/�'�� Office Use Only O1''Y`��i`L +, t' t �(? i- / r/ 2- Permit# __Lr/"�' , 0i i , j JJ//y Amount 50,a,SATTAt€1'CSF ,,,+. .,.gyp e o Permit expires 180 days from issue date 6 c-n---gA-QO 7 EXPRESS BUILDING PERMIT APPLICATION TOWN OFYARMOUTH RECEIVED Yarmouth Building Department 1146 Route 28 J�N � 7 2022 South Yarmouth,MA 02664 (508) 398-2231 Ext. 1261 — BUILDING DEPARTMENT CONSTRUCTION ADDRESS: 35SO• A4MONS11‘ -------'—" ASSESSOR'S INFORMATION: € b �,tuAl ' Map: Parcel: OWNER: ktCMA€L VE tA14G.,Oa SN 7,os.0N r 02100 0 NAME O'' � PRESENT /ADDRESS TEL. # Gin Sp'8O CONTRACTOR:K -11 i(�1:10 ,.'�c,- Wt.. (20 . {.PUS: 02,0S tS 5Dci t-1 toy 0 NAME MAILING ADDRESS TEL.# V Residential ❑Commercial Est.Cost of Construction$ 2200 Home Improvement Contractor Lic.# 12 (S7 Construction Supervisor Lie.# fi I.b? Workman's Compensation Insurance: (check one) (I 0 I am the homeown r ❑ I am the sole proprietor I have Worker's Compensation Insurance Insurance Company Name: �1 Worker's Comp.Policy#6S VLU&c1.1D 4S5DV`(2_I WORK TO BE PERFORMED Tent E. Duration (Fire Retardant Certificate attached?) Wood Stove E Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares 5 ( Remove existing*(max.2 layers) Insulation n EnOld Kings Highway/Historic Dist. 0)Replacing like for like Pool fencing n V Z. *The debris will be disposed of at: 0�M`k 1 - -� L Location of Facility I declare under penalties of perjury that the statements he " 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 ' 1 re cation f my li nse d for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signatu e. Date: • 2 ::::::ttute (or attachment) Date: j 2 Date: 2_2 Building cia desia ee) EMAIL AD j SS: Zoning District: Historical District: : Yes No Flood Plain Zone: Yes `- No Water Resource Protection District: Within 100 ft.of Wetlands: Yes No Yes No KELLY ROOFING PH. 508 509 4640 8 Rhine Road MA C.S.L. #099167 Yarmouthport MA H.I.C.R.#128957 MA 02675 INSURED May 30'2022 Proposal Submitted to Mr. Michael Kelley of 35 South Shore Drive, South Yarmouth MA We propose to supply all materials and labor required to remove and replace the existing Double Layered 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. All Roof Decking Secured Ice and Water damage protection membrane to be installed over Complete Roof Area. Install Certainteed Landmark limited lifetime warranty Architect style Shingles, Using all Certainteed Starters and Cap Shingles to maximize available warranties, (Color to be Specified) All shingles to be storm nailed (6) Repair all flashings as necessary. Install Certainteed Filtered ridge Vent on Ridge with hand Nailed Caps Replace all Plumbing Vent Pipe Boots With new. Complete Clean up off all areas including all gutters and all nails after project complete. Obtaining Of Town Permit At a total cost of$2,200 Payment Schedule; Balance upon Completion Proposal Submitted by: Oliver Kelly Proposal accepted by: 1: j Loix.:41 T rnin$jr,i Date. CD / 3 /2022 a-k- Best Contact Phone Number: ' (,t }• 8 t 1.800 Et r ze#rx.+ti T y rn �► ? k This proposal is valid for 30 days from date above, please Co (3.. .S. 3 51&v call to verify thereafter. The Commonwealth of Massachusetts . t �"�' Department of Industrial Accidents 411— - I Congress Street,Suite 100 '�i►=_ � 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 Plearint Legibly se P Name(Business/Or anization/lndividual): Vlct 1- r WC. Address:( R.h.w-e• 1LOJP City/State/Zipt4A Pc)2 ,k p$ -- Phone#:5S S 462 D Are employer?Check the appropriate box: Type of project(required): I. lama employer with ( employees(full ardlor Pars-time), 7. ❑New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.[No workers'comp.insurance required.] 3.0 i am a homeowner doing all work myself.[No workers'comp.insurance required.]* 9. El Demolition 1.0 0 Building addition 4.0 tam a homeowner and will be hiring contractors to conduct all work on my property. t will ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.0 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 right of exemption per MGL c. 14.0 Other 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 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 p iding workers'compensation insurance for my employees. Below is the policy and job site information.Insurance Company Name: (lb _ 44,t. 1.0/4- i Policy#or Self-ins.Lic.#:(DS 620 684)S56 3V 9 Expiration Date: �A ' 2o2 Job Site Address: .67.2 S . c 1O.,tz a. City/State/Zi til-412 6 69 Attach a copy of the workers'compensation policy declaration page(showing the policy number and espiratioddate). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violationpunishable 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$250,00 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 h • s nder the pains and penalties of perjury that the information provided above is true and correct: Signatu $` . Date: v ( K) ( 7 Phone#: O€ W9 1-43q0 . ii (Official use only. Da not write in this area,to be completed by city or town official f 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#: ACR CERTIFICATE OF LIABILITY INSURANCE °ATE`MM,°°"YYY). 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 PHONE Q : (508)775-1620 FAX (A/C.No: ADDRESS: Isunivan@doins.com 973IYANNOUGH 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: 775627 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. IN R TYPE OF INSURANCE ADM SUBR POUCY EFF POLICY EXP JNSD WVD POUCY NUMBER (MMIDD/YYYY) (MMIDD/YYYY), OMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ PRO- POLICY JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE UABIUTY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ — ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE _ AUTOS (Per accident) $ $ UMBRELLA LAB OCCUR EACH OCCURRENCE $ EXCESS LAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATIONOTH- AND EMPLOYERS'LABILITY Y/N X PER ER A ANYPR PRIE ERPARTNE /EXXECUTIVE N/A N/A N/A • E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER 6S62UB8H08580922 05/10/2022 05/10/2023 (Mandatory If yes,describe under E.L.DISEASE-EA EMPLOYEE $ 500,000 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 Falmouth ACCORDANCE WITH THE POLICY PROVISIONS. 59 Town Hall Square AUTHORIZED REPRESENTATIVE Falmouth MA 02540 n Daniel M.Crowley,CPCU,Vice President-Residual Market-WCRIBMA 01988-2014 ACORD CORPORATION. All rights reserved. ACORD 26(2014/01) The ACORD name and logo are registered marks of ACORD 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 Office of Consumer A ors&business ref(if" 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 06/13/2023 1000 Washington Street -Suite 710 OLIVER KELLY Boston,MA 02118 OLIVER M.KELLY 2 • 1.� 8 RHINE RD. /(104v� i YARMOUTHPORT,MA 02675 Not valid without signat re Undersecretary • Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards ConstructiQkVS' t1piJi'Vispr Specialty CSSL-099167 Epires:09/28/2023 OLIVER M KELLY 4, 8 RHINE ROAD YARMOUTH P9RT MAC Q2675 O1ti1'Fic%cc 2 :. Commissioner aelci i. 7rli,n(