The URL can be used to link to this page

Home My WebLink AboutBLD-23-001968 1, a� L17'1 /� //f/`L Office Use Only O i '3 Amount `W ` u,, ` Permit expires 180 days from`� `y issue date EXPRESS BUILDING PERMIT APPLICATION C / V E TOWN OF YARMOUTH Yarmouth Building Department OCT 13 2021 1146 Route 28 1 __.._._ South Yarmouth, MA 02664 ' Bu l - -P RT E gy_ (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 5 �/ A- ASSESSOR'S INFORMATION: Map: Parcel: OWNER: tU- C1..,AS5 J �E7.32A .k A _ ` jk C�%Ltok:0I NAME PRESENT ADDRESS TEL. # 203 Lilo 7295- ** )" CONTRACTOR: r' U- -r c `� ! ( Z•t la \:i•: - iliii-M,17"...iai .+C7 t P J -1 c NAME MAILING ADDRESS TEL.# GY v _�c%r. :.t C"s if f, El/Residential ❑Commercial Est.Cost of Construction$ I 23 5'O Home Improvement Contractor Lie.# .. !S Construction Supervisor Lie.#l '(t_j i r r Workman's Compensation Insurance: (check one) ❑ I am the homeowner ❑ I am the sole proprietor ® I have Worker's Compensation Insurance 4c_ '" "aSAN Worker's Comp.Policy#.'i� yt �3'ii t;)4.� °0 f Insurance Company Name: _ 27 WORK TO BE PERFORMED Tent C Duration (Fire Retardant Certificate attached?) Wood Stove El Siding: #of Squares Replacement windows:# .,,. Replacement doors: # Roofing:V#of Squares 2 6 (a Remove existing* (max.2 layers) Insulation I I 1 Old Kings Highway/Historic Dist. Replacing like for like Pool fencing 11 *The debris will be disposed of at: .4—' 4- -, `irt ,`-1.-i-,-~C: 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 revocation of my license and rosecution under M.G.L.Ch.268,Section 1. e� Applicant's Signature:' C #l1 /V Date: / / 06 / 2.2 Owners Signat re(ar attachment Bate' Approved By: /4//r2 Date: ‘,./ ..- /4/ .2 2 Building Official(or ign EMAIL ADDRES • Zoning District: Historical District: Yes No Flood Plain Zone: Yes No Water Resource Protection District: Within 100 ft.of Wetlands: 7 Yes No Yes No . t The Commonwealth of Massachusetts Department of Industrial Accidents t-= Office of Investigations 1, y l� ir.,:. , ,- Lafayette City Center 2 Avenue de Lafayette, Boston,MA 02111-1750 '`:•t!, �0 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information ��((' Q , '" �,,` Please Print Legibly IK u E Name (Business/Organization/Individual): 1 FO � t' Address: t 4")'. City/State/Zip: PO2t M/k O24 7S Phone#: 50 e. 50q 14 640 Are ou an employer?Check the appropriate box: Type of project(required): 1. I am a employer with i 4. 0 I am a general contractor and I 6. ❑New construction employees (full and/or part-time).* have hired the sub-contractors 2.❑ 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. 0 Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp. insurance comp. insurance.: required.] 5. 0 We are a corporation and its 10.❑Electrical repairs or additions 3.❑ 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.ErRoof 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: AOC. AM.eiztc.j*. — Policy#or Self-ins.Lic.#: 65. 0 61)14,0465(60e12.2.. Expiration Date: .6 `_L 6 (0. 923 Job Site Address: 55 ti 0....) c-A City/State/Zip: S✓• am°( '`f `' 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify and' the pains and penalties of perjury that the information provided above is true and correct. Signature: * I' Date: ID i S 2.2_ Phone#: SO$ So c 4.b40 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 30City/Town Clerk 4.0 Erectrical Inspector 50Plumbing Inspector 6.0Other Contact Person: Phone#: /7�P CJ�/�2/ 2C//m tec g,l e/ '�CG�1'^J-acids Pii ' 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 Affairs&Business if-6gufition HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only before the expiration date. If found return to: TYPE:i Individual x Office of Consumer Affairs and Business Regulation Registration Expiration 1000 Washington Street -Suite 710 128957 06l13l2023 Boston,MA 02118 OLIVER KELLY OLIVER M.KELLY i/�� - 8 RHINE RD. ��er Not valid without signet re YARMOUTHPORT;MA 02675 Undersecretary Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Constructiopr'SlhigVi6pr Specialty CSSL-099167 Ejcpires:09/28/2023 OLIVER M KELLY f. 8 RHINE ROAD ; k YARMOUTH R9RT MA $2675 1 Commissioner J'w fi. U611c:t a_ • 0,r% Curb Mounted Solar Venting Unit $2,200 Add a Factory Installed Solar Blind To Any Unit For Additional $450 Proposal Submitted by: Oliver Kelly 2C2-2- Proposal accepted by: Date. SS' / . /2021 Best Contact Phone : 2.Q 3 - `f'1 --7 2`l 5 This proposal is valid for 45 days from date above, please Call to verify thereafter. A !�® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 05/17/2022 1 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 Pmic.HO No.Extk (508)775-1620 i FAX .Nam): AADDRESS: iullivan@doins_com 973 IYANNOUGH RD INSURER(S)AFFORDING COVERAGE NAIC# HYANNIS MA 02601 INSURER A: ACE AMERICAN INSURANCE CO 22667 INSURED 1 INSURER B: KELLY ROOFING INC INSURER C: _ —_ INSURER D: I 8 RHINE RD INSURER E: 1 YARMOUTHPORT MA 02675 _INSURER F: 1 COVERAGES CERTIFICATE NUMBER: 775626 REVISION NUMBER: THIS IS TO CERTIFY POLICIES HAVE BEEN ISSUED ND CATED. NOTWITHSTANDING ANYREQUIREMENT, TERM ORCOND BELOW ION OF ANY CONTRACT O OR O HER DOCUMENT WITH RESPECT TO POLICY THE INSURED NAMED ABOVE FOR THE PERIOD 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. t TSRR TYPE OF INSURANCE !AiNsOISwvo R POLICY NUMBER (MMIDD/YYYY)I(MMioor(YYY)POUCY EXP I LIMITS COMMERCIAL GENERAL LIABILITY 1 j 1 ) EACH OCCURRENCE 1$ 1 DAMAGE TO RENTS lCLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) 1$ N/A PERSONAL S ADV INJURY I$ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 1 PRO POLICY 1 JECT LOC PRODUCTS-COMP/OP AGO $ OTHER: I I$ AUTOMOBILE LIABILITY ) 'I COMBINED SINGLE LIMIT >'$ t(Ea accident) I I BODILY INJURY(Per person) $ ANY AUTO ALL OWNED I SCHEDULED AUTOS N/A BODILY INJURY(Per accident) $ NON-OWNED AUTOS PROPERTY DAMAGE $(Per accident) i , HIRED AUTOS AUTOS 1$ UMBRELLA LIAB I OCCUR I EACH OCCURRENCE I$ EXCESS LIAB 1 CLAIMS-MADE ( N/A l AGGREGATE I$ J j DED 1 RETENTIONS JI 1�/ 1$ !WORKERS COMPENSATION I I X I PERTUTE 1 1 OOERTH I AND EMPLOYERS'LIABILITY Y I N I E.L.EACH ACCIDENT $ 500,000 A OFFICER/MEMBEREXCLUDED? NIA NIA NIA 6S62UB8H08580922 ANYP R OPRI ETOR/PARTNER/EXECUT IVE 05/10/2022 05/1012 3 I E.L.DISEASE_EA EMPLOYEE!$ 500,000 (Mandatory in NH) If yes,describe under I I E.L.DISEASE-POLICY LIMIT($ 500,000 DESCRIPTION OF OPERATIONS below N/A 1 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may he 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. 1 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 1 issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification 1 Search tool at www.mass.gov/Iwd/workers-compensation/investigations/. 1 i L CANCELLATION CERTIFICATE HOLDER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN