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HomeMy WebLinkAboutBLD-22-007278 r C Ic(>1 11Z,2 Office Use Only ht/+� 41.. � `�3' Pennjt# tn� 70t#1_2� Y.�-r:n Ft i Amount 57/4155 °`5 Permit expires ISO days from issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH RECEIVED . Yarmouth Building Department �._.� 1146 Route 28 South Yarmouth, MA 02664 JUN 17 2022 (508)398-2231 Ext, 1261 CONSTRUCTION ADDRESS: IV\ a—VW\ 4vE E '{ Q� BUILDING D—EPARTMENT ASSESSOR'S INFORMATION: (� I Map: t I Parcel: OWNER[tL_ tk .LQAtN. 1 Px- tlo )Pro 4& Oi5 NAME n PRESENT ADDRESS TEL. # CONTRACTOR: (' Wj P -li ,- 45 atA3G _ q.P M O2,b"1E Spy,S`JCt N(Oil 0 NAME MAILING ADDRESS TEL.giede :a2nt7 YI Residential 0 Commercial Est.Cost of Construction S 3000 Home Improvement Contractor Lie.# I2FcR 67 Construction Supervisor Lie.# C CI I.(07 Workman's Compensation Insurance: (check one) Cl I am the homeown r 0 'Cole the sole proprietor I have Worker's Compensation Insurance Insurance Company Name: A2c4 Worker's Comp.Policy#OS)LO P$U D�.5€C)Ci 4 WORK TO BE PERFORMED Tent !J Duration (Fire Retardant Certificate attached?) Wood Stove E Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares b (0)Remove existing*(max.2 layers) Insulation I t 1 Old Kings Highway/Historic Dist. (0)Replacing like for like Pool fencing El "The debris will be disposed of at: �FD�4wl nata,�� LI Location of Facility !declare under penalties of perjury that the statements - contained arc true and correct to the best of my knowledge and belief. I understand that any false answer(s) will be just cause for • re on f my li se d for prosecution under ivi.G.L.Ch.268,Section 1. Applicant's Signal Date: o•.it�°2 Owners Signature(or attachment) Date: 2 Approved By: 7 7 2 Building Date: Officia ) EMAIL ADD S: Zoning District: Historical District: 7 Yes No Flood Plain Zone: _: Yes = No Water Resource Protection District: Within 100 ft.of Wetlands: Yes No ::. Yes ' No A�RD CERTIFICATE OF LIABILITY INSURANCE DATE`MM(D°"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 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 poticy(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 Linda Sullivan DOWL)NG&O'NEIL INSURANCE AGENCY PHONE , ,, (508)775-1620 FAX (AW.NO: Wass: Isuliivan©doins.com 973 IYANNOUGH RD INSURER(S)AFFORDING COVERAOE NAICS HYANNIS MA 02601 INSURER A: ACE AMERICAN INSURANCE CO 22667 INSURED INSURER B: KELLY ROOFING INC INSURER c: INSURER D: 8 RHINE RD INSURERE: 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. ILL TYPE OF INSURANCE .18111.20612., POUCY NUMBER POLICY EFF POLICY EXP (MMIDDYYY/ Y) (1MIIDOIYYYYY YI LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE n OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ • MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE UNIT APPLIES PER: GENERAL AGGREGATE $ POLICY !ecr LOC PRODUCTS-COMP/OP AGG $ OTHER $ AUTOMOBILELIABIUTY COMBINED SINGLE UNIT $ (Ea dent) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED _AUTOS AUTOS N/A BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE _ HIRED AUTOS _ AUTOS (Per accident) • - . UMBRELLA UAB — OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE N/A AGGREGATE $ DED J RETENTIONS $ WORKERS COMPENSATION E AND EMPLOYER&LIABILITY Y/NANYPROPR X S MUTE ER A OF tiIMIETORI X TNERIE CUTI NIA NIA NNA 6562U88H08580922 05/10/2022 05/10/2023 EL EACH ACCIDENT $ 500,000 (Matrdalory in NH) E.L.DISEASE,EA EMPLOYEE $ •500,000 I yes,describe under DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY UNIT $ 500,000 N/A • DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,maybe 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.govlivid/workers-compensationvestigations/. CERTIFICATE HOLDER CANCELLATION • • SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL• BE DELIVERED IN Town of Lakeville ACCORDANCE 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 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 ✓:n izr(,'€7 ��:-'n��� ��ation Office of Consumer A irs 1#usi'ness 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 Bo ston,MA 02118 OLIVER M.KELLY / t--...C2...CD1 s RHINE RD. ,(0.4t.s.ssr Not valid without signat re YARMOUTHPORT,MA 02675 Undersecretary Commonwealth of Massachusetts 9-1 Division of Professional Licensure Board of Building Regulations and Standards ConstructiotrtuperI Itv r Specialty CSSL-099167 ` t spires:09/28/2023 OLIVER M KFLLY * • f 8 RHINE ROAD ��` ' YARMOUTH PART MA O 5 i C Commissioner da�lla I. t�• ckra� r The Commonwealth of Massachusetts . t =_ '� Department of Industrial Accidents _' i ii= t 1 Congress Street,Suite 100 e E g Boston,MA 02114-2017 -. :,...4 .� www mass gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. . TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information +/' Please Print Legibly Name(Business/Or 'on/Individual): V`c (:Z)43.a Wlv- ( c. Address:"b 1•1..tNc. LAD City/State/Zipp11, i1,(90(-X' 40 1c Phone#: OS 6CR 4!¢`• 0 A employer?Check the appropriate box: Type of project(required):i. i am a employer with ( employees(full and/or part-time).* ?. Q New construction 2.0 lam a sole proprietor or partnership and have no employees working forme 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 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10❑Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.❑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'camp.insurance.: 13. 00f repairs rightexemption per MGL c: 14.0Other 6.0 We are a corporation and its officers have exercised their of 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. lithe sub-contractors haveemployees,they must provide their workers'comp.policy number. I am an employer that isp fling workers'compensation insurance for my employee& Below is the policy andjob site information. Insurance Company Name: atC Policy#or Self-ins.Lin#: =, �} 1 . -7on� v� �� � � SK-�v��f Expiration Date:b. t C.S. G. Job Site Address: Ib ; 'p, & v/I-V 1CLNC City/State/Zip:C % sia1, / l"ti 40966fr 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 h der the pains and penalties ofperjury that the information provided above is true nd correct. Signaler VOW' /' 7 Date: V sosi /, c-t c Phone#: �g `- to-to .. Official use only. Do not write in this area,to be completed by thy or town official City or Town: Permit/License# FIssuing Authority(circle one): - 1.Board of Health 2.Building Department 3.City/Town CIerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other. Contact Person: Phone#: