Loading...
HomeMy WebLinkAboutBLD-23-001267 Off. AR C a!ii,_ q �/a/in 'Office Use Only Y lY� (.� _e0c4j___1: �. 4 1 Permit# • ..P. 1 C Amount O . $ ��,,~',Voa.rMSC, /3 — -3 � Permit expires 180 days from c� 't,/" i issue date 6 6 a,z. "1 RECEIVED EXPRESS BUILDING PERMIT APPLICA DOA0 g �p2 TOWN OF YARMOUTH Yarmouth Building Department BUILDING DEPARTMENT 1146 Route 28 By: South Yarmouth, MA 02664 (508 398-2231 Ex 1261 CONSTRUCTION ADDRESS: 3 z, 'V . _ .A... a) q..L/A,3—J Pvp_c Al oD('Ic ASSESSOR'S INFORMATION: Map: Parcel:OWNER: • '4`) ` °J pao.Nivo z , .t— NAME PRESENT ADDRESS TEL. # "p ,. 2---101V4,,. (�_ D ��n (��CONTRACTOR° v. .mil- IVY I 1� °"1A 0_61S ct �y t(C� NAME MAILING DRESS TEL.# SOS : 09J Id'Residential ❑Commercial Est.Cost of Construction$C,14 00 /.2 (Home Improvement Contractor Lic.# 57 Construction Supervisor Lic.# 09 9/6 7 Workman's Compensation Insurance: (check one) D I am the homeowner ❑ I the sole proprietor ❑ I have Worker's Compensation Insurance �y�l t���� (j Insurance Company Name: 4e /i'�7 �C� Worker's Comp.Policy#6�u�O `� 2 WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares t,� Replacementwindows: # Replacement doors: # Roofing: #of Squares 2-1 ( i' )pl Remov existing* (max.2 layers) Insulation V Old Kings Highway/His oric Dist. ( )Replacing like for like l t a' kVi k\Oct-. ./J4-4-t . q/-7/2, ,� � fecies` G C `14 af- *The debris will be disposed of at: 412. 11 i ).Sv" re Location of Facility I declare under penalties of perjury that the statements herein o fined are true and correct to the best of my knowledge and belief. I understand that any false answer(s) will be just cause for r t cation of my licen for pro ecution under M.G.L.Ch.268,Section 1. 22 Date: Applicant's Signatur . Date: ` Approved By: Owners Signature(or attachment) �y �� I. Date: " Building Official esiQ EMAIL ADDRES • Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: ❑ Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes ❑ No 0 Yes The Commonwealth of Massachusetts Department of IndustrialAccidents :',— ,___: , Office of Investigations ! �t r; Lafayette City Center ' '•`_ ,_ l 2 Avenue de Lafayette, Boston,MA 02111-1750 www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information 4 �(�� Please Print Legibly Name(Business/Organization/Individual): 'A.i U}- t�-`�`-' �'���'� — Address:% C/---kknAl\:) .., Qc: A City/State/Zi.: f \ -S +" y� 13on #: Are y u an employer?Check the appropriate box: Type of project(required): 1. I am a employer with 1 4. L] I am a general contractor and I 6. Q New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sale proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have 8. D Demolition working for me in any capacity. employees and have workers' 9 0 Building addition [No workers' comp. insurance comp.insurance.t required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I I_fl Plumbing repairs or additions myself [No workers' comp. riglt of exemption per MGL 12.E Roof repairs insurance required.]t c. 152,§1(4),and we have no 13.DOther 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 providing workers'compensation insurance for my employees. Below is the policy and job site information. /� Insurance Company Name: A � �� Policy#or Self-ins.Lic.#: Cd `F-��0''(C ket 0 %Expir ttiion Date:- 5 . Z O c'3 Job Site Address: �` � � 3 -V tIJ �> City/State/Zip: A2A r '"� 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 e ins and penalties of perjury that the information provided above is true and correct. • Date: Signature: 0 � ` Phone#: SO% $OJe3t L1 U O 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): 1DBoard of Health 20 Building Department 3=]City/Town Clerk 4.Q Electrical Inspector 5 'lumbing Inspector 6.DOther Phone#: Contact Person: 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 July 27, 2022 Proposal submitted to The Owners in relation to Roof Replacement at 38 Mary David Road, Yarmouthport MA. We propose to supply all materials and labor required to remove and replace the existing Asphalt Roof on The Complete building at the address above. Protect all walls, Windows, shrubs, plants etc. during roof strip. All debris to be removed to town transfer. 8"White Aluminum Drip Edge to be installed on all eaves. 5" On All Rakes. Ice and Water damage protection membrane to be installed on first Six feet of all Eaves. 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$9,400 Comprising of$3200 for Laundry Area Remainder$6200 For#38 Proposal Submitted by: Oliver Kelly Proposal accepted by: Date. 8 / /2022 This proposal is valid for 45 days from date above, please Call to verify thereafter. 4 N aeb(32-49--A5) CC) pAl 0,7 frt. LAc-' 1 o' (.annell -----"1 e DATE(MM)DD)YYYY) A�n CERTIFICATE 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(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 CONTACTNAME: Linda Sullivan DOWLING &O'NEIL INSURANCE AGENCY PHOE HON No.Ext): (508)775-1620 FAX ,No): E-MAIL ADDRESS: Isullivan@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 0: 8 RHINE RD 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 SUBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE INSD WVO POLICY NUMBER (MM/DD/YYYY) (MMIDONYYh COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED 1 CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ MED EXP(My one person) $ N/A PERSONAL 8.ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ PRO- POLICY JECT LOC PRODUCTS-COMP/OP AGG $ $ OTHER: COMBINED SINGLE LIMIT $ AUTOMOBILE LIABILITY (Ea accident) BODILY INJURY(Per person) $ ANY AUTO ALL OWNED I SCHEDULED N/A BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $HIRED AUTOS AUTOS (Per accident) $ • UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED 1 I RETENTION$ $ WORKERS COMPENSATION X STATUTE ERH- AND EMPLOYERS'LIABIUTY - Y/N E.L EACH ACCIDENT $ 500,000 AFFICER/M ETOR/PXCLUDEDXECUTIVE N/A N/A N/A 6S62UB8H08580922 05/10/2022 05/10/2023 A OFFlCaR/MEMNEREXCLUDED? E.L.DISEASE-EHEMPLOYEE $ 500,000 (Mandatory in NH) II yes,describe under E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS below N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) clams for enefits to employees in state be s otherfd o thanMassachusetts achusetts lif thesinsured hires,or has Endorsement h hired those employees outside of Massa6 B,no chusetts. on is given to pay --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_mas.gov/Iwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL •BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of Lakeville 346 Bedford Street AUTHORIZED REPRESENTATIVE Lakeville MA 02347 Daniel M.Crowley,CPCU,Vice President—Residual Market—WCRIBMA I ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 26(2014/01) The ACORD name and logo are registered marks of ACORD - \ tyff oi/ #ea-,)-3-ah;t4,-)eili-}' 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-05/17 Office of Consumer Aft irs:#idusiness I€��5tion HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only before the expiration date. If found return to: TYPE:Individual Office of Consumer Affairs and Business Regulation Re128957on Exp3 2023 1000 Washington Street -Suite 710 128957 06/13/2023 Boston,MA 02118 OLIVER KELLY OLIVER M.KELLY % ' Of2C2—d 8 RHINE RD. LK�1,a Not valid without signat re YARMOUTHPORT,MA 02675 Undersecretary Commonwealth of Massachusetts Division of•Professional Licensure Board of Building Regulations and Standards Construct 1l4 pr Specialty CSSL-099167 ., Eicpires:09/2812023 OLIVER M KELLY ,- .f ; 8 RHINE ROAD YARMOUTH PART MA 02675 � .. r �` _ f, r/ -N;A ''(t!'4., 1 at�Z Commissioner dicvii2 A. 7164.1ct'_to,- } ; - , , : - . I 7 fit: t` r i . c I ,- c i\ r -:', ,-„cF,,,,,..,- :•:.' cif. ,' 'if,I I - ,,,c.,tilt''--$: : ' ' ' 11/1:1;1:li:( 4 5� 'I f ttt �.. i ' . iiiiiii7;;',11:::" '. , i — 1 i': , ill Ili it,, 1/1.,'„1 , ., ,1,1, i , i /-,/ :// • -,_ ‘ , „t , i . . k \\tt , 1/1 f14/1,,,/' ; .t . ,, „, I /1;11' 4. . ttU It ri /� ,i. at�1 -, .. . ., I��]�Yye • l 11/), i,„ w � , ,a a 1 I )I , ill ;t `i - I ilifLof'llilifitd �»eiR i iifi .1,,,. i\J i,,,, , ), a, ;� ��! 0 A" , `,# Y %Fill - ,5 11';'1 1 i1i a s. s 3r, � � _ * • ,p fi. � ,t +!i OF fi' �.. k v' \ ,Ito t y,. i*r ii 1. • •�` t�.�� �� "F : +� r • 1 '7S' A,ti F t 1.;-7-4 ' • ' .7-*''-'-'';'1174'p.-iC‘lij, to„'",.• ' M '{ J fit, ''' ' . .1.-t*.i-'..." .. , A : : Ili +� w .:It .i-- i ',,cn ,� y��gyl fLywT' - ...„, :C::: - ":''-'‘ I.7 044 4,$ '['1 j S 3.°' ,:,::kit, ; -, iy.,,-....,„..,,,,,,,,e, ...,..,_. ix i T< 1 L , \,. 1 ..,si0 ,, t',- ,,,,, •--,' ,,,•••„,. ••.. --!1 ;',-41:1,:....k::.0..,- ,3,,i.;;;01..,,,ir:',....1'tn,t.:*. , ,,, . .e.,„.1,...„, .,. tt." Jr "ff�rir.MY; *IN; }•OF. T C t �� �� r .`� P ` .L "i;� � 'i' 1,, 1 • 'fir