The URL can be used to link to this page

Home My WebLink AboutBLD-23-000943 o.f p��2I�/� RECEIVED Office Use Only g 4 O or - V (� -__ -- Permitn (� re AUG 2022 Amount �, ve nnrr atn zs[ ,�, y �41 _ Permit expires ISO days from BUILDING DEPARTMENT issue date 8&-n—a 3--deo94..3 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: q ;1- L1 Cr a✓ .. .11 7Z'40j" ASSESSOR'S INFORMATION: Map: Parcel: OWNER:Lk)412-a i '116oYLI‘.)Cj GsuGIAT► 4.......,...,..., qt 80b1SrNAME PRESENT ADDRESSL. # CONTRACTOR: KS1.4.1 RO0C. .?X. V'IC. S L Yc.. QD i ilin,)1.4 f%Cc 144- o laic NAME MAILING ADDRESS 1 TEL.#v0:'3: „' r,Is,ar,^= Residential El Commercial Est.Cost of Construction S igloo Home Improvement Contractor Lic.# E25S9. 7 Construction Supervisor Lic.# 9. .b 7 Workman's Compensation Insurance: (check one) ' ❑ I am the homeown r 0 I am the sole proprietor Di have Worker's Compensation Insurance Insurance Company Name: A Worker's Comp.Policy* 2.t)16 SI4V, CsS WORK TO BE PERFORMED Tent E. Duration (Fire Retardant Certificate attached?) Wood Stove Li Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: it of Squares 27 (la Remove existing (max.2 layers) Insulation 7 {" ( Old Kings Highway/Historic Dist. Replacing like for like Poui feu.:ittg Li vie 2 o-vAie kNiNd- i a O iL . �, 4 -wsi l Y/ay l'T,,P'Phis will he disposed of at: 4 1'QAiti1[ . t caution of Facility I declare under penalties of perjury that the s. men s here" contained are true and correct to the best of my knowledge and belief. I understand that any false r..s 4.;) will be just cause for denial or-relocation . my*_. .,'d for prosecution under M.G.L.Ch.26S,Section 1. l Applicant's Signature: kk,. ---411" ,. A I ,6- 1 2 Owners Signature(or attach ,e i <f Date: L A2 ,,,,,- Approved By: 7L/ __, Date: !T423 . .v.,.......b LI-Z,Zui svi i_sswe /AIi.tviH3L HULKtsS: Z nnina ilicfi ir} Histnriral ilia Y,.: N., Ft,...A�—:—' ... -- `.':: _. N: Water Resource Protection District: Within 100 ft.of Wetlands: ._ Yes No -_ Y's • N0 _, _o The Commonwealth of Massachusetts - -4 Department of Industrial Accidents IJI—�-,�If:;." Office of Investigations .. .`: Lafayette City Center =„:-_ 2Avenue de Lafayette, Boston,MA 02111-1750 www mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): AL (NV L Address: 6 K-- .Kj E, ' /may., ‘ .(City/State/Zip: t i 1 VP1 J2 " #: 5`n �CU "1,b �0 Aru an employer?Check the appropriate box: en Type of project(required): 1_ I am a employer with 4. 0 I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6 El New construction 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. ❑Demolition working for me in any capacity. employees and have workers' [No workers' comp.insurance comp.insurance.? 9. ❑Building addition required.] 5. ❑ We are a corporation and its 10.0 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 12.12 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. 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 t....,e 4 ��( i-.V Policy#or Self-ins.Lic.#: (pS (02 0 P.D S a so6 Expiration Dater Z 2 Job Site Address: 61 � �4.1G1-.!fLt . City/State/Zip: , `A) �! OZ7S' Attachworkers' � l'�a copy of the 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 corr t Sisature: 0 r Date: 1 Z L Phone#: 0 (46" 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 313City/Town Clerk 4.❑Electrical Inspector 5Elumbing Inspector 61DOther Contact Person: Phone#: AC R° CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 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 IN PHHONNo,Exti: (508)775-1620 FAx E-MAIL (A/C,Noy: ADDRESS: isuinvan@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 TYPE OF INSURANCE ADM SUBR POLICY EFF POLICY EXP LTR INSD WVD POUCY NUMBER (MM/DD/YYYY) IMM/DD/YYYY) 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 I JE 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) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED I RETENTION$ WORKERS COMPENSATION X PER STATUTE I ERH AND EMPLOYERS'LIABIUTY Y/N ANYPROPRIETOR/PARTNER/EXECUTI VE A OFFICER/MEMBEREXCLUDED? N/A N/A N/A 6S62UB8H08580922 05/10/2022 05/10/2023 E.L.EACH ACCIDENT $ 500,000 (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/1wd/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.Crowley,CPCU,Vice President—Residual Market—WCRIBMA 01988-2014 ACORD CORPORATION. All rights reserved. ACORD 26(2014/01) The ACORD name and logo are registered marks of ACORD /Ge Gzf22/2 o/m( CGCG 2/ Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Individual OLIVERKELLY Registration: 128957 IN 8 LIVER Expiration: 06/13/2023 YARMOUTHPORT,MA 02675 Update Address and Return Card. SCA 1 0 20M-05/17 ✓f.� Yii..i iiii•i-i.///. ss'kOfice ofaCconsumer Affv $dusieE'dl1 ti on HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Individual before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 128957 06/13/2023 1000 Washington Street -Suite 710 OLIVER KELLY Boston,MA 02118 OLIVER M.KELLY 8 RHINE RD. � YARMOUTHPORT,MA 02675 Undersecretary Not valid without signat4lre Commonwealth of Massachusetts Division of-Professional Licensure Board of Building Regulations and Standards Construction,, peh1*$pr Specialty CSSL-099167 Expires: 09/28/2023 r OLIVER M KELLY 1 8 RHINE ROAD YARMOUTH PART MA 02675 {%I\S 1 tll"° Commissioner u f;. i.7Cen