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HomeMy WebLinkAboutBLD-23-000541 edt— .01- �Yq�,1 w" l I Office Use Only. }' s,`�2 -r gymz_ Permit# C J/r� 6 O V of Amount .. (2 del cs)NATT I n s �*"""'' E Permit expires 180 days from issue date &9-02-3 —13695q1 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH RECEIVED Yarmouth Building Department ��---- ----- 1146 Route 28 AUG 0 2 2022 South Yarmouth,MA 02664 (508) 398-2231 Ext. 1261 BUILDING DEPARTMENT B14-414:017— : CONSTRUCTION ADDRESS: 2 / 82 &4-t�j ASSESSOR'S INFORMATION: Map: Parcel:OWNER:S 141N1e rL01044 C 021 I1 EQ 6-4 )sera 4d /42.,QJq /9- 0265 NAME PRESENT ADDRESS TEL. # CONTRACTOR: Kg W ROCC. X. `i1G. S Pt.& t.040 1o " cbt` 14. Or2 b1 S' NAME MAILING ADDRESS ' M TEL.#5oeg Sal LtftX10 St esidential ❑Commercial Est.Cost of Construction$ Home Improvement Contractor Lic.# IniCtS7 Construction Supervisor Lic.# O`(ct I 67 Workman's Compensation Insurance: (check one) 0 I am the homeown r 0 I am the sole proprietor e I have Worker's Compensation Insurance Insurance Company Name: te..444 Worker's Comp.Policy# WORK TO BE PERFORMED Tent II Duration (Fire Retardant Certificate attached?) Wood Stove rE Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares lb (Z)—Remove existing*(max.2 layers) Insulation El I Old Kings Highway/Historic Dist. (3 Replacing like for like Pool fencing n *The debris will be disposed of at: `142a4C4*-7 'A-42‘A 014-- 1 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 ocation of my I11 d for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: J • Date: ' ?. 22 r Owners Signature(or attachment) ,�y Date: `. 2� Approved By: `' a��2 Date: Building Official(or designe EMAIL ADDRESS: Zoning District: Historical District: 1 Yes 7 No Flood Plain Zone: 7 Yes 7 No Water Resource Protection District: Within 100 ft.of Wetlands: Yes J No E. Yes 'IT The Commonwealth of Massachusetts Department oflndustrialAccidents Office of Investigations ` 4 ! Lafayette City Center 2 Avenue de La fayette,Boston,MA 02111-1750 www.massgov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Letibly Name(Business/Or 1/ �� J Q( ganiza6on/Individual : L Address: U Q \)E, City/StateiZip: Pk.QS O2-61 #• 50` �O 9 4.fC 4.0 Are ypu an employer?Check the appropriate box: 4. I am a Type of project(required): 1. I am a employer with ` ❑ general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. New construction 2.0 I am a sole proprietor or partner- listed on-the attached sheet. 7. 0 Remodeling ship and have no employees These sub-contractors have 8. (l Demolition working for me in any capacity. employees and have workers' 9 Buildingaddition [No workers' comp.insurance comp.insurance required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3.0 I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12 Roof repairs insurance required.]t c. 152,§1(4),and we have no employees. [No workers' 13.0 Other 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 providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:A eL Policy#or Self-ins.Lic.#: (DS c02 NS 22 5 tO �� `��`t�Expiration Date:- Job Site Address:2! e� � p City/State/Zi : Td'� .- '�/44.04l90 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify and % and penalties of perjury that the information provided above is true and correct: i • 1 Signature: •�- Date: _ 2. ( L... Phone#: �j°C5 601- IA Lig Official use only. Do not write in this area,to be completed by city or town official. • City or Town: Permit/License# Issuing Authority(check one): 10Board of Health 20 Building Department 3.0City/Town Clerk 4.0 1lectrical Inspector 5t'lummbing Inspector 6.:Other Contact Person: Phone#: ACO o® CERTIFICATEDATE(IMr/ODIYYYY) �.� 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: ff the certificate holder is an ADDITIONAL INSURED,the pollcy(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 E,di ( )775-1620 i FAX 1(A/C.No): DRAD ; Isuthvan@doins.com 973 IYANNOUGH RD INSURER(S)AFFORDING COVERAGE NAIL# HYANNIS - MA 02601 INSURER A: ACE AMERICAN INSURANCE CO 22667 INSURED KELLY ROOFING INC INSURERS_ 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. INSR ADDL SUER EXPPOLICY EFF POLICY trg LTR TYPE OF INSURANCE INSD w POLICY NUMBER (e D yy) ( M/OD/YYYY►. LBWS COMMERCIAL GENERAL I rewt rrY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTED • PREMISES(Ea occurrence) $ . MED EXP(My one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: 1POLICY PRO- GENERAL AGGREGATE $ JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILELIABIUTY 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 _ AUTOS PROPERTY DAMAGE $ (Per accident)_ _ $ UMBRELLA LAB OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE N/A AGGREGATE $ DED 1 f RETENTION$ WORKERS COMPENSATION $ AND EMPLOYERS'LIABILITY Y/N X STATUTE OTH- ER ANYPROPRIETOR/PARTNER/EXECUTIVE EL EACH ACCIDENT $ 500,000 A OFFICER/MEMBEREXCLUDED? WA N/A WA 6S62UB8H08580922 05/10/2022 05/10/2023 (Mandatory in NH) 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 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-compensationlnvestigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES 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 I Daniel M.Crowley,CPCU,Vice President—Residual Market—WCRIBMA ACORD 26(2014/01) The ACORD name and logo are ©1988-2014 ACORD CORPORATION. All rights reserved. og registered marks of ACORD • t 67-4 rOy 9 272 20-/2/Ill-ed./(0 A/&CG,,./-"9 Ce- /X.3 Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Individual OLIVER KELLY Registration: 128957 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 rs :Dusmess ie4ffrahon 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. ( . YARMOUTHPORT,MA 02675 Undersecretary Not valid without signat re Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards ConstructiotT'3Vpieipr Specialty CSSL-099167 ! 6cpires:09/28/2023 OLNER M KEILY s j 8 RHINE ROAD YARMOUTH P/RT MA 5 -' / 1 OISS"l d0)V Commissioner dam fi. t" nii..,