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Home My WebLink AboutBLD-22-007147 C41- u1g12 RECEIVED Y Office Use Only `r `zoo FJIMalp&dPermit# C1,O 1," 7/1tif Amount �V s\ rwr-nenC�c!, -- ---- ;, ;v BUILD Q 'ARTMENT Permit expires ISO days from By. 1 issue date BID —(72 a--tl&91 LP) EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department • 1146 Route 28 South Yarmouth,MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS:04 maw) (-.. /i.,U' l "-Wow-: (J v �' _ ASSESSOR'S INFORMATION: Map: I Parcel: OWNER: ali2.60 iii:PLC..:� v-i/( f ,4,1 r 1 4.1 7 w,, /. Aolvelf # i" 2673 NAME PRESENT ADDRESS TEL. CONTRACTOR:kali Qo.2 - 45 Q 4tAt ) . 14..PE.) IAA 0217'1S 50%50ct .i rogo NAME MAILING ADDRESS TEL.ft residential ()Commercial Est.Cost of Construction S 7 900 Home Improvement Contractor Lic.# t2 5q S7 Construction Supervisor Lie.# Oat-1 I.b7 Workman's Compensation Insurance: (check one) 0 I am the homeown r ❑ I am the sole proprietor I have Worker's Compensation Insurance Insurance Company Name: r. AIIE21C4 Worker's Comp.Polio V S )2 )8>ci '!U ) V"t Z WORK TO BE PERFORMED Tent Ei Duration (Fire Retardant Certificate.attached?) Wood Stove E Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares 17 1 (El)Remove existing*(max.2 layers) Insulation 1 riOld Kings Highway/Historic Dist. 3 Replacing like for like Pool fencing El 'The debris will be disposed of at: I �-�'' t �`G _ Location of Facility declare under penalties of perjury that the statements hefeio 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 rei+ocat'on f my iiQr e. d_four prosecution under M.G.L.Ch.268,Section 1. 6 Applicant's Sign �.� ' X . Date: ZZ : 1:t0ratment) 172._ c: 9 ZZ.Date: ' Building Official(or desi ) EMAIL ADDRESS: Zoning District: I Historical District : Yes No Flood Plain Zone: 2 Yes = No 1 Water Resource Protection District: Within 100 ft.of Wetlands: Yes No Yes No 1 The Commonwealth of Massachusetts =V e!t Department of Industrial Accidents � 1 Congress Street,Suite 100 `�;i_ Boston,MA 02114-2017 ' =x www.mass.gov/dia Workers'Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information +f Please Print Leeibly Name (Business/Or anization/Ind'vidual): U�� '`Q' C (mac' Address:4)(Business/Or CAD City/State/Zip. ` Phone#: `� & 4 4 (i IAA�� '�—t 4-4-,(Pc �b� Are yo employer?Check the appropriate box: - Type of project(required): 1. I am a employer with ( employees(full and/or part-time).* 7. ❑New construction 2.0 I am a sole proprietor or partnership and have no employees working for mein 8. []Remodeling any capacity.[No workers'comp.insurance required.] 9. Demolition 3.0 1 am a homeowner doing all work myself.[No workers'comp.insurance required.] 10 Q Building addition 4.E.1 I am a homeowner and will be hiring contractors to conduct all work on my property. t will repairs or additions Electrical[] ensure that all.contractors either have workers'.compensation insurance or are:sole 11. 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. 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 c. 14.❑Other 152,§I(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 thoseentities have employees. If the subcontractors have employees,they must provide their workers'comp.policy number. l am an employer that is pr !ding workers'compensation insurance for my employees. Below is the policy and job site information. ,, Insurance Company Name: W M,t�ICA Policy#or Self-ins.Lic.#:`�S V 20 tJ'Btkv S3 0V 9 Expiration Date: ' 10 ° 202 W( u3 tov St-.Poi Q� City/State/Zip. . yate/Zip. Wi4. OOP Job Site Address: ' bdf Attach a copy of the workers'compensation policy declaration page(showing the policy number a d expiration ate): 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 '-, -nder the pains and penalties of perjury that the information provided above is true and correct Signature �r 1 Date: �J (f 29 Phone#: gSOI `" 104.0 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): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 7 KELLY ROOFING PH.S08 5091840 8 Rhine Road MA C.S.L.8 099187 Yarn outhport MA H.I.C.R.I 128957 MA 02675 INSURED April 13' 2022 proposal submitted to Mr.Carlos Perez of 289 Winslow ay , MA. We propose to supply all materials and labor required to Gr removeRoad andWest replace the Protect existing Doyle layered asphalt roof on the house at the address above. all walls.Windows,shrubs,plants etc during roof strip. All dobns to be removed to town transfer. 8'White Aluminum Drip Edge to be installed on all eaves.5'On all Eaves. Ice and Water damage protection membrane to be installed on first six foot of all Eaves. r Remainder Of Roof To be Covered With Synthetic Roof Underlayment. Install prnited 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 then Limited Lifetime Warranty Landmark Series Shingle Replace plumbing vent pipe boots with new. Instal!CeRainteed Filtered Ridge Vent with hand nailed caps. Complete Clean up off an areas including all gutters and all nails after project complete At a total cost of$7,900 To Remove Rear Porch roofing material,install plywood and Shingle Roof as above Add$4200 Payment Schedule:Balance upon Completion Proposal Submitted by:Oliver Kelly Proposal accepted by: •,•�:- Data�/IL9 2022 This proposal is valid for 30 days from data above,plump call to verify thereafter. Best Contact Number: 4 2:re., -'j ( 4 ''.'4 gyp'; ` c Pt A►cR® CERTIFICATE DATE(WII/DO/YYYY) �,-^� 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 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 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 CONTACT wage Linda Sullivan DOWLING&O'NEIL INSURANCE AGENCY PHONE FAX r�rrN (•` )775-1620 INC,M: Ai Ess: Isullivan@doins.com 973 IYANNOUGH RD HYANNIS INSURER(s)AFFORDING COVERAGE NAIL# MA 02601 INSURER A: ACE AMERICAN INSURANCE CO 22667 INSURED KELLY ROOFING INC INSURER C: : 8 RHINE RD INSURER D: 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. LN TR TYPE OF INSURANCE POUCY NUMBER (raMAXWYTYY) (MI POUCYEMI ) LINTS COMMERCIAL GENERALUABN.ITY _ EACH OCCURRENCE $ CLAIMS MADE OCCUR • PR S Ea�acamence) $ • MED EXP(Arty one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY 1-1JECT- I I LOC PRODUCTS-COMP/OP AGG $ $ OTHER - AUTOMOBILE LIABIU rY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL OWNED r----SCHEDULED BODILY INJURY(Per person) $ AUTOS AUTOS N/A BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED AUTOS (PR�OPEntDAMAGE $ $ UMBRELLALWB OCCUR — EACH OCCURRENCE $ EXCESS LIAR "_ CLAIMS-MADE N/A AGGREGATE $ DED j RETENTION; WORKERS COMPENSATION PER $ AND EMPLOYERS'LIABILITY Y/N X STATUTE ER EM A OFNFlC)EROMMEMBEREXCL NIA WA WA 6S62UB8H08580922 CUTIVE E.L EACH ACCIDENT $ 500,000 (Manda OFFICE /Min NH) 05/10/2022 05/10/2023 If yes describe under • EL 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,maybe attached it 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 issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Cove e-Cov icy ra precedes the Search tool at www. ass.gov/twd/workers-compensationfinvestigations/. m9 rage Verification tTi CERTIFICATE HOLDER CANCELLATION • THE EXPIRATION DATESHOULD ANY oF THE OVE THEREOF, NPOLICIES T IE WIL •L CANCELLEDEE BEFOREIN Town of Lakeville ACCORDANCE WITH THE POLICY PROVISIONS. 346 Bedford Street AUTHORIZED REPRESENTATIVE Lakeville i MA 02347 Daniel M.CroWiey,CPCU,Vice President—Residual Market—WCRIBMA ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks o ACORD f� 'rzuecdIP- //gc ,� �. e� ;� 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-OS/17 .Z Fi<YJ//J7/�//!'Pl/ ,/ �ffe & ushers [' Office of Consumer irs �usiness'i�f��iif5tion 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 ��"� 8 RHINE RD. Iou�~ �. YARMOUTHPORT;MA 02675 Not valid without signat re Undersecretary • • Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Constructi�oii' perlts6r Specialty :' CSSL-099167cpires:09/28/2023 OLIVER M KgLLY1 8 RHINE ROIL YARMOUTH TORT S r 5 .r •��C�[S'�k€L}� Commissioner daickf'. t71C1m�Jtla 1 •