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HomeMy WebLinkAboutBLD-22-007146 C-•I-" 4/62-,` R E C E I V E D Office Use Only Amount ;'"+j ) I [3F PARTMENT TI Permit expires ISO days from BUI By: issue date & D--01a-M71 140 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 26t. Lr_SOQALS ` jv.QAyVL _ ASSESSOR'S INFORMATION: Map: I Parcel: OWNER:VoRtc5tinl }4(1.- IA65 1 ►RAJ" 50 &c ew- I .S `(1.4. % �(d42.�.5`G-� 1 MGs— NAME PRESENT ADDRESS TEL' #4_\S.,riN=A.JME.S4QgA CONTRACTOR:fttLL'i 0.0.2c--u3G- Qti+ A . �. � 02,6?ssc, oci (,qU Cam( NAME MAILING ADDRESS TEL.4 �I Residential °Commercial Est.Cost of Construction S 'OC) Home Improvement Contractor Lie.# 1 L )°(S7 Construction Supervisor Lie.# CA CI L b7 Workman's Compensation Insurance: (check one) D I am the homeown 0 I am the sole proprietor I have Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy VS 62k)& itZ ceJ�L1`"4 2( WORK TO BE PERFORMED Tent L Duration (Fire Retardant Certificate attached?) Wood Stove C Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares (0)Remove existing*(max.2 layers) Insulation I ) riOld Kings Highway/Historic Dist. (Q)Replacing like for like Pool fencing ��rip '�G 'The debris will be disposed of at: !A _\ lTs- Location of Facility i declare under penalties of perjury that the statements h 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 • re 'on f my Ii tie for prosecution under M.G.L Ch.268,Section I. Applicant's Signal ` Date: 6 .c) ) 2- Owners Signature(or attachment) Date: Z_ Approved By: Date: 2-2._ Building Official(or desi MAIL ADDRESS: / • Zoning District 1 Historical District :_ Yes No Flood Plain Zone: __ Yes == No Water Resource Protection District: Within 100 ft.of Wetlands: Yes No ::= Yes No - � r • The Commonwealth of Massachusetts * , !/.. Department of Industrial Accidents e1_ � 1 Congress Street,Suite 100 _ i r. g Boston,MA 02114-2017 -,=�" www.mass gov/dia 1!� Workers'Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Or anization/Individuai): Ui.-t V-o (t%.3 C- Address: �twz. LOAD City/State/ZippIA D it POPJc .4 e9Solc Phone#:50S 5ECt 4 V-t 0 Are yo employer?Check the appropriate box: Type of project(required): 1. i am a employer with employees(full and/or part-time).* 7. 0 New construction 2.01 am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.[No workers'comp.insurance requited.] 9. ❑Demolition 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 0 Building addition 4.0 I am 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 moprietois with no employees. 12.0 Plumbing repairs or additions JO tam a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. oof repairs These sub-contractors have employees and have workers'comp.insurance:: 6.0 We are a corporation and its officers have exercised their right of exemption per MGL e. 14.0 Other 152,I1(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. tContractors 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 employee& Below is the policy and job site information. _ Insurance Company Name:f C, �Ce,4.I Policy#or Self-ins.Lic.#;G5 620( kO85 DV? Expiration Date: ° t 0 a 20 3> Job Site Address: 2=l SA���0 S i1q+t- City/State/Zipk% q4Q.M()0 �� " 0 2 661 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiratioh 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$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 here nder the pains and penalties of perjury that the information provided above is true and correct. Si natur Date: 2 9 Phone#: 7g "' l `"t (4.0 i 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# I AC RBI' CERTIFICATE OF LIABILITY INSURANCE DATE `" DINYYTY) 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'poiicy(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 CONTACT NAME: Linda Sullivan PHO FAX DOWLING&O'NEIL INSURANCE AGENCY , ,' , ): (508)775-1620 ,N,); A ADDDREDRESS: vanG Isuili doins.com 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 INSIJRERE: 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. LTRTR TYPE OF INSURANCE SD POLICY NUMBER (MM/DD/YYYY) !D/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S GE TO CLAIMS-MADE OCCUR PREMISES ENTEDa ) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEM.AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO n JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea aca.i enn ANY AUTO BODILY INJURY(Per person) $ —ALL OWNED SCHEDULED AUTOS N/A BODILY INJURY(Per accident) $ _ AUTOS NON-OWNED PROPERTY-DAMAGE HIRED AUTOS — AUTOS (Per accident) T $ UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS LUAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTIONS - $ WORKERS COMPENSATION X Sg TUTS OTH- ER AND EMPLOYERS'LIABILITY ANYPROPRIETOR/PARTNERIEXECUTIVE Y/N E.L EACH ACCIDENT $ 500,000 A OFFICER/MEMBEREXCLUDED? WA N►A N/A 6S62UB8H08580922 05/10/2022 05/10/2023 (Mandatory in NH) E.L.DISEASE-J_AEMPLOYEE $ 500,000 If yes,describe under 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/lwd/workers-compensationMvestigations/. • CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL•BE DELIVERED IN Town of BarnstableACCORDANCE WITH THE POUCY PROVISIONS. 200 Main Street AUTHORIZED REPRESENTATIVE Hyannis MA 02601 Daniel M.Crow ey,CPCU,Vice President—Residual Market—WCRIBMA 1 ©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 OLIVERIN KELLY Registration: 128957 8 IVER Expiration: 06/13/2023 YARMOUTHPORT,MA 02675 Update Address and Return Card. SCA 1 0 20M-05/17 tcycOffice of Consumer es'$um sess$ guui 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 06/13/2023 1000 Washington Street -Suite 710 OLIVER KELLY Boston,MA 02118 OLIVER M.KELLY ``-'G Y O 8 RHINE RD. a. k YARMOUTHPORT,MA 02675 Not valid without signet re Undersecretary Commonwealth of Massachusetts t) Division of Professional Licensure Board of Building Regulations and Standards Constructia0311 4(v/i&pr Specialty CSSL-099167 } ipires:09/28/2023 OLIVER M KELLY * 5 8 RHINE ROAD YARMOUTH P.�RT MA 5 r = Commissioner dia f;. CvntLA S ' ^` EV, 4 KELLY ROOFINGr F.- =i = a Rhine Road PH.eo lt0e . g i . i { �' 167 rrnoumport MA 6 MA HAMA.*12ep6T xAI y * k . May 24'2022 � fu kk . Propose? INSURWo submitted 10��Owners V�R 6�A1Y�11MIa• :,,,�y�T #s .4 kd- 4 � - Yf N Propose to supply all materials .sash Yj x existing Asphalt roof at he address and required to remove � �` s ", a ;. . Protect all walls.Windows,shrubs, : Wants etc.during root strip, .z'gr x �� a sfi All debris to be removed to town transfer. 0 ! , P S4 l 8'White 'i x ,, AMm�tum Drip Ede be lnafaNsd on al eaves 8'On '. All Roof Decking Secured b Ice and Water ' . $ k Ice and dsma_ protection membrane to be installed ,, - ,� = ReRlaindero( � IM six leM Oil* W F Root Deck to be Covered with Sic Underlayment j �t�n C • .,irfi • Certaintee Starters Cap Shinglesmark Imited oArchitefd stye Shingles,Using , ! r - ' maximizeavailable warranties,(C olor-to bet a All shingles to be storm nailed(8) Repair all ltashmgs as necessary Install Cerlsinteed Filtered ridge Vent 0n All Ridges with hand NaRsd. Replace all Plumbing Vent Pipe Boots With new. ,°. ., Complete Clean up oft all areas in cluding all7SIOP AA .;�h, 4 Obtaining Of Town Permit ;' , �_ 74 > trAt a fatal cost cat 8,9pD p• payment 3cfieldule•8aisnce • >� Proposal 3ubmoltea by:°river Kelly !# 'p --l accepted b♦ �t G �+ F .�G."Y`x & A .t .t'3�2 �` S x Beg Cp'Nad Phone Number: - . `% #'3{tt rah 4 i. il'4M. 5 a.- ,a `Y' u k .: - 4 e t o t be ,,..„i, iii... '.'7'''''', ,r','':,,, ''''-,,-7''' :,i -77.1,7'7.-', ;:'. . :::'-fill'i:Y:!-.'i'7;T:E:i'i_';';‘*!4-,.2.L'%:t.';:'.:';'-',''.-;r:17;-:';1.:$,'..; :-.:;--:':si'jt,;41!',;:liCt-;...,f,'!'"t.,,17';-7,$,1:9iiA)10.„ftili: 7.:' '7: : 7:': -.:r:''.;.; ''''''',';;;,•:' '','''''; r i'i'4 ' � _ �.; s Y _ Sy } pr �af`i , ` y� k