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HomeMy WebLinkAboutBLD-23-001452 .., C all t a CH Zxl,i Z2 Office Use Only t Permit# eil J�, O• • �l y. Amount yl— .U •ce ...,-Ft M S d -..$),'........--E Permit expires 180 days from issue date .-02.3 -60/Lf55 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH RECEIVED Yarmouth Building Department 1146 Route 28 SEP 19 2022 South Yarmouth, MA 02664 (508) 398- 1 Ext. 1261 'Ull QING DEPARTMENT " LA136. G, Air I r r CONSTRUCTION ADDRESS: C.- ` �" ASSESSOR'S INFORMATION: Map: 2 Parcel: A ,j OWNER:&40 esk"m.A., J✓ g....,..x,c,..... ib +woo.) "'V- 0 2(f ME q� oPRESENTADD SS1/4) • :cm `� ! ' CONTRACTOR:U`W \ U 4,0 1J Q "��` t1'/ - Qj$� NAME MAILING ADDRESS r + TEL#SU- 509 ii ro CZl o Residential 0 Commercial Est,Cost of Construction$ 10, Home Improvement Contractor Lic.# I 159 5 7 Construction Supervisor Lic.# £Y3< I h7 Workman's Compensation Insurance: (check one) 0 I am the homeowner ElI the sole proprietor 0 I have Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy# 6206 ist1O 5$ £J' WORK TO BE PERFORMED Tent J__.I Duration (Fire Retardant Certificate attached?) Wood Stove El Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares t0 ('Remove existing*(max.2 layers) Insulation n E101d Kings Highway/Historic Dist. Replacing like for like Pool fencing I I *The debris will be disposed of at: �7 l'2 U I�'�+` 44 6+,�^ po Location of Facility I declare under penalties of perj • at the statements herein :•to• . . e true and correct to the best of my knowledge and belief. I understand that any false answer(s) will be just cause for de.'. I .evoca'on of license:I• s • secuf'n under M.G.L.Ch.268,Section I. /D Applicant's Signature:L 4 ' Date: Q.'17 nl ` Owners Signature(or attachment) , /`� 'A Date: 9, / f` 2-2._ Approved By: Date: l/ GS' Building Offici, (or d ne EMAIL ADD' : Zoning District: Historical District: Yes No Flood Plain Zone: _ Yes C_ No Water Resource Protection District: Within 100 ft.of Wetlands: Yes No .__ Yes No L. Commonwealth of Massachusetts {� Division of Professional Licensure Board of Building Regulations and Standards Constructie03I4itSpr Specialty CSSL-099167 Expires: 09/28/2023 OLIVER M KELLY 1. rtn 8 RHINE ROAD YARMOUTH PORT MA 02675 ;- I I Commissioner dtrickf'. 1:i ca, ro_mm,0_/-4efieadlo/y&o.-44exeli(4_ax)_ 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 C 20M-05/17 fiy{Office of Consumer Aftrus&Business FF'6!UiStion 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 Boston,MA 02118 OLIVER KELLY 8 RHINE RD. '�" ° Not valid without signat re YARMOUTHPORT,MA 02675 Undersecretary The Commonwealth of Massachusetts Department of Industrial Accidents 7 _ L, Office of Investigations ` ¢— .; Lafayette City Center 2 Avenue de Lafayette, Boston,MA 02111-1750 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information 1�f� Please Print Lei=ibly Name(Business/Organization/Individual : fC L i� �"4 Z _ Address:9 Qx \ �1 City/State/Zip: y +" A'\ O #: Are y u an employer?Check the appropriate box: Type of project(required): 1 J✓J l am a Hoye.with 4. n I am a general contractor and I b Q New construction employees(full and/or part-time).* have hired the sub-contractors listed on the attached sheet. 7. ❑Remodeling 2.❑ I am a sole proprietor or partner- ship and have no employees These sub-contractors have g. []Demolition working for me in any capacity_ employees and have workers' 9 Building addition [No workers' comp.insurance comp.insurance.t required.] 5. We are a corporation and its 10.0 Electrical repairs or additions 3_ D I am a homeowner Aping all work officers have exercised their 11_0 Pipmhinarepairs ar adriirlcans right of exemption per MGL myself. [No workers' comp. 12.E oof repairs insurance required.]t c. 152,§1(4),and we have no employees. [No workers' 13.❑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. 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:App tL� Policy#or Self-ins.Lic.#: `0 2 0`� 2 l� j E Expiration Date:. 5 t 0 - �—� ,� Job Site Address:��`.LJ' 1::-LIQC:Y City/State/Zip `. ., 'Ill 264 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 ins and penalties of perjury that the information provided above is true and correct. Signature: Date: ( tdi Phone#: $'J —t aUl" F J 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 3tCitylTown Clerk 4.0Electrical Inspector 5.0'lumbing Inspector 6.DOther Contact Person: Phone#: DATE(MM/DD/YYYY) ACORO® 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 policy(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 CONAME: Linda Sullivan DOWLING& O'NEIL INSURANCE AGENCY Paco.NNo.Ext): (508)775-1620 Fa,No): ADDRESS: Isu Ilivan@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 INSURER C: INSURER D: 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 OF INSURANCEADDL SUER POLICPOUCY NUMBER (MMIDDY EFF POLICY EXP TYPE LTRINSD WVD /YYYY) (MM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ D AMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY I PRO JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) _ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED - SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE _ HIRED AUTOS AUTOS (Per accident) UMBRELLAUAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X STATUTE OTH- ER AND EMPLOYERS'LIABILITY Y/N ANYPROPRIETOR/PARTNER/EXECUTIVE EL.EACH ACCIDENT $ 500,000 A OFFICER/MEMBER EXCLUDED? N/A N/A N/A 6S62UB8H08580922 05/10/2022 05/10/2023 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 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/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 Town of Lakeville ACCORDANCE WITH THE POLICY PROVISIONS. 346 Bedford Street AUTHORIZED REPRESENTATIVE Lakeville MA 02347 Daniel M.Crowey,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 26(2014/01) The ACORD name and logo are registered marks of ACORD ARD® DATE(MM/DD/YYYY) '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 policy(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 PHONi n Ext): (508)775-1620 Fax E-MAIL (A/C,No): ADDRESS: ISu lliva n@doi ns.corn 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 INSURER E: YARMOUTHPORT MA 02675 INSURER F: COVERAGES CERTIFICATE NUMBER: 775629 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 LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY1 LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $ $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO - BODILY INJURY(Per person) $ ALL OWNED SCHEDULED T AUTOS _ AUTOS N/A BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE AUTOS (Per accident) $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ WORKERS COMPENSATION X $ AND EMPLOYERS'LIABILITY Y/N STATUTE I ERH ANYPROPRIETOR/PARTNER/EXECUTIVE EL.EACH ACCIDENT $ 500,000 A OFFICER/MEMBER EXCLUDE D? N/A N/A N/A 6S62UB8H08580922 05/10/2022 05/10/2023 (Mandatory in NH) If yes,describe under E.L.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,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/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 Town of Mashpee ACCORDANCE WITH THE POLICY PROVISIONS. 16 Great Neck Road North AUTHORIZED REPRESENTATIVE Mashpee MA 02649 t` �x i Daniel M.Crowley,CPCU,Vice President—Residual Market—WCRIBMA ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD