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HomeMy WebLinkAboutBLD-23-003540 - on I L,I J 0)22- Office Use Only r y \,11Qq Permit:': 50,6 tQ .< I'," Amount t! j.3.31,.3 :„. YAT'AC 3'F/_, ':,_,��,:4;.,., :c <+ Pennit expires ISO days from ` issue date 13(,,i) 3 06354 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH - Yarmouth Building Department R E C E I V E D 1146 Route 28 South Yarmouth, MA 02664 DEC 2 8 2022 i ' (508) 398-2231 Ext. 1261 _____ A 1 lli � / , BU LDING DE PAR-rMENT CONSTRUCTION ADDRESS: ` LA..)1 7- 't 0 ,.31JS r ASSESSOR'S INFORMATION: Map: I Parcel: i! c�� OWNER: [1(' 'LA-`� s.._1.# A.Nt l ih�s ;"� 1 ..5 3g . :X7. \-(�9,,Z1.{.£L3�1LA MAO2bbL/ NAME PRESENT ADDRESS TEL. N CONTRACTOR:(tU-y c,‘")c,- C . apt t- 93 - q-Pc . OZb"1S So%3oci N b4'0 NAME MAILING ADDRESS TEL.# YJ Residential 0 Commercial Est.Cost of Construction S 1 ,2CC' Home Improvement Contractor Lie.# 12 q S/ Construction Supervisor Lie.•# CPIcj I.b7 Workman's Compensation Insurance: (check one) 0 I am the homeown r 0 I am the sole proprietor I have Worker's Compensation Insurance Insurance Company Name: L.S.A.C-0A-1 Worker's Comp.Policy:6S 6?-0&ci '!U t�SV`(Z WORK TO BE PERFORMED Tent . Duration (Fire Retardant Certificate attached?) Wood Stove E Siding: #of Squares Replacement windows:# Replacement doors: # � Roofing: #of Squares Z (� ('''l )Remove existing*(max.2 layers) Insulation I 7 Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing 11 "t vl.J::'M J1..t�c.1�S1--c *The debris will be disposed of at: i 1 Location of Facility t declare under penalties of perjury that the statements he 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 re tion of my li nse_ d for prosecution under M.G.L.Ch.268,Section I. Applicant's Signatu . Date: � .2 -.) ZZ Owners Signature(or attachment) Date: /2 2 Approved By: A Date: 2 Building ci de once) E I ADDRESS: Zoning District: Historical District: Yes No Flood Plain Zone: _: Yes = No Water J2esource Protection District: Within 100 ft.of Wetlands: I Yes No :. Yes No �''�r� The Commonwealth of Massachusetts Department of Industrial Accidents l� I Cbxgress Street, Suite 100 Boston, MA 02114-2017 — _ www.mass.g �� ovldia orkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly c ' n Name (Basiness/Orga '}}don/individual): -(.. L`�`� Ki� J i rat, t'l. 1 (; ` r V 1 Address: ) � -\,`�} �,: --�� . - City/State/Zip:\'1/14r)-iV;a:) 1Al“ J' \ u . Phone#: - e t t `` t_ C Are you an employer?Check the appropriate box: Type of project(required): 1. am a employer with ( employees(full and/or part-time).* 7. E New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. LI Remodeling any capacity.[No workers'comp.insurance required.] ' 3.J I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑Demolition 10 C Building addition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will . ensure that all contractors either have workers'compensation insurance or are sole 11.Q Electrical repairs or additions proprietors with no employees. 12_[]Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet 1-, [Rioof repairs These sub-contractors have employees and have workers'comp.insurance.$ 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.0 Other 152,§1(4),and we have no 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 contracts s must submit.a new affidavit indicating suck 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 pro 'ding workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: =,• : \A' 2.l 3 Y 6S -. .-.--- _ , -:- • ,- , ,-* '-'-' '1/ {,% \ 1 •L1 d V�(� p c � ( 1 L�`? Policy#or Self-ins,Lic. #: �� x iration Date: ' Job Site Address: t Of- n ,d �,+1' '��, 6 City/State/ZiPE-J) ' ' ' Attach a copy of the workers' compensation policy declaration page(showing the policy number and Expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby�`cer ' uide th ,ai and penalties of perjury that the information provided above is true and correct. /') t Signature: ✓ Date: r� t L- / 2_ / '- (__ - Phone i#: '`l t t,o ( 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 (circle one): . • I.Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: ACORl7 CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/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 CONTNAME: Linda Linda Sullivan DOWLING &O'NEIL INSURANCE AGENCY NE tgic. Ext): (508)775-1620 rAI,No): ADDARESS: Isullivan@doins.com 973 IYANNOUGH RD INSURER(S)AFFORDING COVERAGE NAIC HYANNIS MA 02601 INSURER A: ACE AMERICAN INSURANCE CO 22667 INSURED INSURER B: I KELLY ROOFING INC INSURER C: INSURER D: 8 RHINE RD INSURER E: YARMOUTHPORT MA 02675 INSURER F: COVERAGES CERTIFICATE NUMBER: 775624 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. NOTVNTHSTANDING 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. INSRADM SUER TYPE OF INSURANCE POLICY NUMBER (M POLICY MIDD EFF POLICY EXP LTR INSD WVD /YYYY) (MMIDD/YYYY) LIMITS LT COMMERCIAL GENERAL LIABILITY EACH OCCURRENCEDAMAGE TO RENTED $ CLAIMS-MADE I OCCUR PREMISES ES(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 J $ 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) I $ UMBRELLALIAB OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE N/A AGGREGATE $ DED , RETENTION$ WORKERS COMPENSATION It STATUTE ERH AND EMPLOYERS'LIABILITY YIN ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,000 A OFFICER/MEMBEREXCLUDED? N/A NIA N/A 6S62UB8H08580922 05/10/2022 05/10/2023 (Mandatory in NH) E.L.DISEASE-FA EMPLOYEE:$ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT I$ 500,000 N/A 1 i DESCRIPTION OF OPERATIONS/LOCATIONS I 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 ACCORDANCE WITH THE POLICY PROVISIONS. Town of Barnstable 200 Main Street AUTHORIZED REPRESENTATIVE Hyannis MA 02601 Daniel M.Crowley,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 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 December 12, 2022 Proposal submitted to Kelly Sullivan of 1 Out Of Bounds Drive South Yarmouth MA. We propose to supply all materials and labor required to remove and replace the existing Double Layered Asphalt Roof at the Address Above. Protect all walls, Windows, shrubs, plants etc. during roof strip. All debris to be removed to town transfer. 8"Aluminum Drip Edge to be installed on all eaves. 5" On All Rakes. All Roof Decking to be Secured. Ice and Water damage protection membrane to be installed on first Six feet of all Eaves and In All Valley Areas. 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$13,200 Proposal Submitted by: Oliver Kelly Proposal accepted by: ,5 cAttp.ri Date. /3 / /2022 Best Contact Phone : 105 This proposal is valid for 45 days from date above, please call to verify thereafter. e/'%GFi 2J19f22f72C-/m/teCGGG GL ,/ CLJ-Jt�'i cZat-Fi'C J'- 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 e- 20M-05/17 Office of Consumer Affairs 81#usmess'ififiur£tion 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 06/73uuts 1A99 Washington Street -Sliite 710 OLIVER KELLY Boston,MA 02118 OLIVER M.KELLY % 00 Q 00.18 RHINE RD. '�`C 1YARMOUTHPORT,MA 02675Not valid without Signat e re Undersecretary Commonwealth of Massachusetts =�C Division of Professional Licensure Board of Building Regulations and Standards Constructiorr'Suir/ispr Specialty CSSL-099167 • Expires:09/28/2023 OLIVER M KELLY -= 8 RHINE ROAD YARM UTHi*RTiiM ORf73 771 4 ' �/• Sw v. .O/SS•110'� Commissioner;0;a,�l� f, UCentyta