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HomeMy WebLinkAboutBLD-23-003195 ' irR E s E 6 V E D ©& ': 0 90 O t�'E a I� Amount v �rnrt n ca_ __ .._. ._ _..... ,-, * wilts:,- BUILDING DEPARTMENT Permit expires 100 days from By:_ ____ issue date CO'fr--3 5-C‘5 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH _ 3 ) C Yarmouth Building Department ��� 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: CALk 'w\�-F\1J Q040 1 L, - ASSESSOR'S INFORMATION: nn 11 Map: Parcel: ' t 1�= 5 Pi-n ka oO Ir,1 �p Ow'r�ER: .�v>� ��-�u�2�� ass `-1t. ;epa ‘kI\- 06b3 NAME PRESENT ADDRESS TEL. #5at '74,1 y 55 y r t CONTRACTOR: k7:: i„3., kf'-;,�=j -ii' t ' '_\,1e i\J e. 't.., :# il-N-0--m- J d ike;-) ' PIA 02-k:n{ NAME MAILING ADDRESS I TEL.#S< �i4 a' if 1:7, tf Residential ❑Commercial Est.Cost of Construction$ 75GO Home Improvement Contractor Lic.# t 6cy Sir ,'7 C' � ��"�r(' s F;l Construction Supervisor Lic.# ► � 1 Workman's Compensation Insurance: (check one) D I am the homeowner 0 I am the sole proprietor I have Worker's Compensation Insurance 4C �+�Ar-�'+.z l fi Worker's Comp.Policy#r 2.ii, `•� '1 `;` �c 2 z Insurance Company Name: 4 WORK TO BE PERFORMED Tent U Duration (Fire Retardant Certificate attached?) Wood Stove El Siding: #of Squares Replacement windows:# Replacement doors: # Roofing:Ii#of Squares tV (I)Remove existing*(max.2 layers) Insulation ri E101d Kings Highway/Historic Dist. J Replacing like for like Pool fencing f *The debris will be disposed of at: l4 i 1 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 m . se and for prosecution under M.G.L.Ch.268,Section 1. '] Applicant's Signature: 'kw,. k 0 Date: 12 / 1 I 22- Owners Sig Lure(or attachment) Date: l Date: ! •4.. — f 2_C Approved By: Building Off al(o signee) EMAIL RESS: Zoning District: Historical District: Yes No Flood Plain Zone: Yes No Water Resource Protection District: Within 100 ft.of Wetlands: Yes No I Yes No l ® DATE(MM/DDlYYYY) ACTOR© 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 CONTACTNAME: Linda Sullivan DOWLING & O'NEIL INSURANCE AGENCY INC.PHONE (A/C. (508)775-1620 FAX (A/C, E-MAIL ADDRESS: Isuliivan@doins.com 973 IYANNOUGH RD IN SURER(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: 77562E 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-IAVE BEEN REDUCED BY PAID CLAIMS. INSR IADDL SUBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE I INSD WVD POLICY NUMBER I(MM/DD/YYYY) (MMIDDIYYYYI COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE 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 PRO- JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: COMBINED SINGLE LIMIT $ AUTOMOBILE LIABILITY (Ea accident) BODILY INJURY(Per person) $ ANY AUTO ALL OWNED SCHEDULED N/A BODILY INJURY(Per accident) $ AUTOS AUTOSPROPERTY DAMAGE NON-OWNED (Per accident) $ HIRED AUTOS AUTOS $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ $ DED RETENTION$ v PER OTH- WORKERS COMPENSATION /� STATUTE ER AND EMPLOYERS'LIABILITY YIN E.L.EACH ACCIDENT $ 500,000 ANYPROPRIETOR/PARTNER/EXECUTIVE A OFFICER/MEMBER EXCLUDED? N/A N/A N/A 6S62UB8H08580922 05/10/2022 05/10/2023 E.L.DISEASE-EA EMPLOYEE $ 500,000 (Mandatory in NH) If 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) ,no claims for benefits to Compensation employees in s will state be s othaid er thansachusetts Massachusettsl thesinsured hires,or has Endorsement h hired those employees o6utside of Massachusetts.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.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 ACCORDANCE WITH THE POLICY PROVISIONS. Town of Lakeville 346 Bedford Street AUTHORIZED REPRESENTATIVE 1,j c, Lakeville MA 02341' Daniel M.CroW y,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD Commonwealth of Massachusetts rr Division of Professional Licensure Board of Building Regulations and Standards CSSL-099167 Expires: 09/28/2023 OLIVER M KELLY 8 RHINE ROAD YARMOUTH PORT MA 02675 Commissioner f),a . I;. GG',,t _ U -2.2/2 --yemoei i '(r1i �':;t:�r' f e'2/7-). 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 n 2OM-05117 U•/vi//'/i/j/X/',,���. f� . ,.'/,•-'i//:. _ Office of Consumer Affairs&Business R4guratmn Registration valid for individual use only HOME IMPROVEMENT CONTRACTOR 9 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 OLIVER M.KELLY 8 RHINE RD. Not valid without signet re YARMOUTHPORT,MA 02675 Undersecretary . The Commonwealth of Massachusetts Department of Industrial Accidents `'_I-=,) ;�___ 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 Please Print Legibly Name(Business/Organization/Individual): k°'41 Lam- t' `fie-' Address:S E. 12.0,41-0 City/State/Zip• l vaDJ p 3`a 02.07G Phone#: 3o 5091 i b y Are you an employer?Check the appropriate box: Type of project(required): 1.ti I am a employer with 1 4. 0 I am a general contractor and I 6 New construction employees(frill and/or part time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition workingfor me in anyaci employees and have workers' coin .insurance.t g- 1:-.]Building addition [No workers comp.insurance P 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 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 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. +Contractors 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. i Insurance Company Name: Y- 9 Policy#or Self-ins.Lic.#: 5�.3.)6 s O12. Expiration Date:.6-to, 'LIJob Site Address:ct"1 r.!-!'^� . •• City/State/Zip:50; {AQWW 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$25(1.00 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 under.the pains and penalties of perjury that the information provided above is true and correct. �.� U.... 1 n Signature: �1 ��. Date: if I ; _ it II Phone#: '00 5041 4 64 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): • IDBoard of Health 20 Building Department 3DCity/Town Clerk 413Electrical Inspector SI'lumbing Inspector 6.DOther 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 November 15'2022 Proposal submitted to Mr. Jim Neithercut of 94 Wilfin Road So.Yarmouth, MA. We propose to supply all materials and labor required to remove and replace the existing asphalt roof on the house 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. Ice and Water damage protection membrane to be installed on first six feet of all Eaves And In All Valley Areas. Remainder Of Roof To be Covered With Synthetic Roof Underlayment. Install limited lifetime warranty Landmark Architect style Shingles, Color to be Weatheredwood All shingles to be storm nailed (6) We Generally Use Certainteed Products with All Accessories to maximize available warranties. This proposal is based on their Limited Lifetime Warranty Landmark Series Shingle Replace plumbing vent pipe boots with new. 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 $7,500 Payment Schedule; Balance upon Completion Proposal Submitted by: Oliver Kelly Proposal accepted by: \ `r',x:. r I/ c �., - ..:�.r)�` Date! / //2022 j • I This proposal is valid for 30 days from date above, please call to verify thereafter. Best Contact Number: