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Home My WebLink AboutBLDX-23-15129 01.Y 44 Office Use Only r 4"'*' ,<4 RECEIVED Wni5i — Z3-/S/ ;9 O y Amount -- ,,,,,a,, . AUG 09 2023 �.. Permit expires 180 days from BUILDING DEPARTMENT issue date By: EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext, 1261 CONSTRUCTION ADDRESS: 2°6 0 W l 'W ASSESSOR'S INFORMATION: 41-0-4A0013,1bitc 2 k� Map: \ \. I Parcel: l OWNER: IJYII( /(4--1161�Q� ` %O Wr. ZIJ vImmA 'tutpotil It`1k 15(2.6-1S NAME PRESENT_ _ ADDRESS TEL. # CONTRACTOR: W1 g �y iA)E t�•olt -6 `� 1,(UTI490 ` 1S NAME MAILING ADDRESS TEL.# SotGol Lb ° Res E idential ❑Commercial Est.Cost of Construction$ p$DO Home Improvement Contractor Lic.# /ZZq 57 Construction Supervisor Lic.# ( qq(&, Workman's Compensation Insurance: (check one) � � 0 I am the homeowner 0 I am the sole proprietor Ibihave Worker's Compensation Insurance Insurance Company Name: ( 1°cam r7 i(.A ) Worker's Comp.Policy# 6562ud8k(oS58072,3 WORK TO BE PERFORMED VELD ZO®c 1106-@ 1 CLOJC)-Cam( Tent El Duration (Fire Retardant Certificate attached?) Wood Stove El Siding: #of Squares Replacement windows:# Replacement doors: # Roofi : #of Squares fu (I IRemove existing*(max.2 layers) Insulation L I ' i* Old hw Kings Highway/Historic g ay/Historic Dist. ReplacijnJ�like for like 4 Pool fencing . Kept o4 Gt t)G GJ rrq 150 C t Q-Q.G-IJYE CT H uJc t c 1-4-2 c L.[kcs *The debris will be disposed of at: ' 1MOQ,5`ril A-1-kc\ASC10.2 CQC Z14 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 or of m�.�`�. prosecution under M.G.L.Ch.268,Section I. Applicant's Signature: �y 9 �3 Date: j� r Owners Signature(or attachment) A "A cci:e0 f 2 Date: Approved By: t Building Offici i Date: EMAIL ADDRESS: Zoning District: Historical District: " Yes I No Flood Plain Zone: C Yes = No Water Resource Protection District: Within 100 ft.of Wetlands: 7- Yes 2 No 2 Yes 2 No • The Commonwealth of Massachusetts ifa Dent of Industrial Accidents Office of Investigations Lafayette City Center 2Avenue de Lafayette, Boston,MA 02111-1750 www r?Zossgov/dia Workers'Compensation Insurance Affidavit:Builders/ContructorstEle+etricirans/Plumbers Applicant Information Pose Print Lestil ly Name(Business/ 'onilndividual): `,k_.i LI- acoct43 Address: % Wi° CAD Ci IStateai : PQ 7 hone ii: 5015 L{ (p U ,Are i u an employ . Check the appropriate box: 1.A 1 am a employer with 4. 0 1 am a general contractor and I Type of project(regained): employees(full annd/on part-time).* have hired the sub-contractors 6. 0 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 S. [l Demolition working for me in any opacity. employees and have workers' [No workers' comp.incur comp.insurance.: 9. Building addition Bui 3.❑ rimed-] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions I am a homeowner doing all work officers have exercised their myself. [No workers'camp, right of exemption per MGL I i.j�Plumbing repairs or additions insurancerequired.]* C. 152, I(4),and we have no 12. Roof repairs employees. [No workers' 13.0 Other comp.insurance required.] *My applicant that checks box HI must also fill out the section below showing ._ f Homeowners who submit this affidavit indicating doing ork and then hire outside PoI s a new. :Contractors that check this box must itwnal sheet showing mute of the ° submitust a or not thosem entities h such. employees. If the a�have 5 ,they must provide their woEdcers' sub-contractors sad sty whether or not those have�►•policy number. .l am an employer that is providing workers'co� - -- ---__��------ rnpensation insurance oremployees. .__.._..___t information. 'e ployeesr Below is the policy and job site Insurance Company Name: 1\CLN"Alt,'''9-k.eaci-N Policy#or Self-inns,kic.#: �1} 3L` G=Z�� Expiration Ddte:_�- -�.�3' 2t�.�f Job Site Address: i5,1� P(� Attach a copyof the City/State/Zip: l 7� workers'compensation policy declaration page(showingthe Failure to secure coverage policy number aa8 expiration date). as required under Section 25A of NIGL c. 152 can lead to the imposition of criminal fine up to$1,500.00 and/or one-yeah imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and of fia ne of up to$250.00 a day against the violator. Be advised that a c Investigations of the 1)IA for. opy of this statement may forwarded the Office of o ansttrance coverage verification. I do hereby..certify under e pains and penal�s o f perjury that the infonn<rdnn i provided above is true and come 1 �fI . Ol1utuseo — - only. Do not write in this _ tow__. area,toe completed __. by city or town official _-—; City or Towne. Permit/License# Issuing Authority(check one): iOBoard of Health 20 Building Department 3DC Inspector 6.(jOther ity/TowB Clerk 4.0Etrica1 Inspector Slumh' ng Contact Person: Phone#: KELLY ROOFING PH. 508 509 4640 8 RHINE ROAD MA C.S.L. #099167 YARMOUTHPORT MA H.I.C.R. # 128957 MA 02675 INSURED. Kellyroofing@icloud.com May 16, 2023 Proposal submitted to Mr. Bruce Raynard of 280 Weir Road, Yarmouthport MA. We propose to supply all materials and labor required to remove and replace the existing Asphalt Roof at the Address Above Protect all walls, Windows, shrubs, plants etc. during roof strip. All debris to be removed to town transfer. Install 8"White Aluminum Drip Edge to be on all eaves. Install 5"White Aluminum Drip Edge On All Rakes All Roof Decking to be Secured. Ice and Water damage protection membrane to be installed on first Six feet of all Eaves, in Valley Areas and around all protrusions. Remainder of roof deck to be covered with synthetic underlayment. Install limited lifetime warranty architect style Shingles, Color To Be Specified, All shingles to be storm nailed (6) We generally use Certainteed products, this proposal is based on their Standard Landmark Limited Lifetime Warranty Shingle. Using all Certainteed Starter and Ridge Shingle Products To Maximize Available Warranties. Replace plumbing vent pipe boots with new. Repair/Replace All Flashings As Necessary Install Certainteed Filtered Ridge Vent with hand nailed caps. Complete Clean up off all areas including all gutters and all nails after project complete. At a total cost of$6,800 Payment Due Upon Completion. Proposal Submitted by: Oliver Kelly Proposal accepted by: Bruce Raynara Date. 05//6/2 /2023 • Commonwealth of Massachusetts IP Division of Professional Licensure Board of Building Regulations and Standards Constructi ( r Specialty CSSL-099167 4 cpires:09/28/2023 OLIVER M KELLY ` a 8 RHMIE RCMP YARMOUTH P4ORT 5 iris 10Isv • 1 Commissioner naefidaf'. b'Gmck.ta.., 16 v E in C R NN i 4 j O zi�(sj p��p ar =p co Ca ` �... C CyN- Q C p cO cn N ° E I � o p 0 �g" .�coa m m 4Q * Pali 1W a < c2 . co 8 .liZsi O RSA C ).a 2 Sa uIH I ' ll z E `� oo' Ooo m � � UT E ` 2 s o mW _ !sue ,u 2 N ffi'o H- =jY F- $ 0 n a � N �. CO aihV +5 z• } o XtP Jai a o k Luz x O 0� v� g J } J 119 CC P- 201 0 0c,)- Ak CERTIFICATE OF LIABI LITY INSURANCE I DATE(MMI2023 Y) 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 poi If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy, must have ADDITIONAL ire an endorsement provisions orA statement endorsed. this certificate does not confer certain policies may require an A on rights to the certificate holder in lieu such sndorasmsrtt(s). PRODUCER CONTACT DOWLING&O'NEIL INSURANCE AGENCY NAME: Linda Sullivan PNONE ate -MAC s.n• (508)775-1620 FAX tA/C.Nol: 973 IYANNOUGH RD ADDRESS: Isullivan@doins.cem HYANNISINSURERI 02601 INS SIAFFORDING COVERAGE /WC I INSUREDMA INSURER ACE AMERICAN INSURANCE CO 22667 KELLY ROOFING INC Issue R e: NSURER C: 8 RHINE RD INSURER D: YARMOUTHPORT INSURER E- COVERAGES MA 02675 INSURER F CERTIFICATE NUMBER: 890310 REVISION ER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED ABONUVE OR 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 LTR TYPE OF INSURANCEADOL SUBR POLY EFF POIJCY EXP COMMERCIAL GENERAL LIABILITY 'misD twD POLICY NUMBER IMIWODIVYYYI IMMIDwyyyyl UNITS CLAIMS-MADE OCCUR EACH OCCURRENCE g DAMAGE TO RENTED PREMISES tEa occur-once] g MED EXP(My are person g N/A GEML AGGREGATE LIMIT APPLIES PER PERSONAL d ADV INJURY $ PORGY PERQ LOC GENERAL AGGREGATE 3 OTHER M PRODUCTS•COMP'OP AGG g AUTOMOBILE LIN ITV g ANY AUTO COMBINED SINGLE LIMIT {Ea YINntl g OWNED ,__,_,.y AU/OSULED N/A BODILY INJURY(Per person) 3 SCHED_ ; AUTOS ONLY HIRED NON OWNED BODILY INJURY!Per accident!$ AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE (Per ascktent1 g UMBRELLA LIAB OCCUR $ EXCESS LIAB CLAIMS MADE NIA EACH OCCURRENCE $3 DEO RETENTION AGGREGATE WORKERS COMPENSATION g AND EMPLOYERS'LIABILITY X PER OTH, AIIYPROPRIETPARTNER>XECUiIVE Y/N STATUTE _ ER. ;ANYPRRPRIETO R ARTNERD? pi NrA WA 6S62U88H08580923 OFFICER n NHI 05/10/2023 05/10/2024 E L.EACH ACCIDENT $ SQO.000 It ySeCfa,DESCRIPTION OF OE.L.DISEASE.EA EMPLOYEE $ S�,000 er DESCRIPTION Of LERATKINS below E I. DISEASE-POLICY LIMIT 3 500.000 NIA DESCRIPTION OF OPERATIONS/LOCATIONS 1 VEHICLES(ACORD NM Additional Remarks Sr-Indult.may Workers"Compensation benefits wiN be paid to Massachusettsa✓ eclrb I more*Pa"Is regnrrNU claims for benefits to employeesemployees only.Pursuant to Endorsement WC 20 03 06 B.no authorization is given to pay 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 e date of Policy Precedes the Searrch tool athwww.massis tgov e of II wd/Workers-compensatwntirrvestigationstnsurance). The status of this coverage�n be Gored daily by accessing the Proof of Coverage-Coverage Verification CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Yarmouth THE EXPIRATION DATE THEREOF' NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 534 Winslow Grey Road AUTHORIjED REPRESENTATIVE South Yarmouth MA 02664 Daniel M.Crowley,CPCU,Vice President-Residual Market-WCRIBMA ACORD 25(2016l03) The ACORD name and Cl 1�2015 ACORD CORPORATION_ All rights reserved. �°are►egisterod marks of ACORD