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Home My WebLink AboutBLD-23-002198 yam; P _ m Y`A. F,.-H �! Office Use Only l�(� 4 O` E g L 'tlYp D Pennitl CK.43�� V fAmount � V OCT 2 4 2022 Vsja � Permit expires 180 days from � issue date F31,i !C- "'�` EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: t 5 <O.J c .1'2.0_, 0 7 K-, (9),D a,31.1" c97 l � r ASSESSOR'S INFORMATION: Map: Parcel: OWNER:cA-I\VS"ILit1/4&\.16i1- . IRVO 4:146 . t:'Nt� Ci.J 52o,c)1 NAME PRESENT ADDRESS TEL. # CONTRACTOR: S -'1 .00C- ally IC.— ("5 tuAL I AAR41 ,)1 .l i i{,S - 02 4,,M. NAME MAILING ADDRESS TEL.#Sec6so9 y� 1 OResidential ['Commercial Est.Cost of Construction$ ;2_ 40 Home Improvement Contractor Lie.# fl_Seti37 Construction Supervisor Lie.# '(07 Workman's Compensation Insurance: (check one) 0 I am the homeownt r 0 I am the sole proprietor 0 l have Worker's Compensation Insurance 7 Insurance Company Name:' '; +t{ Worker's Comp.Policy# SCS-CR WORK TO BE PERFORMED Tent L Duration (Fire Retardant Certificate attached?) Wood Stove El Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares (_ty Remove existing*(max.2 layers) Insulation n riOld Kings Highway/Historic Dist. Replacing like for like Pool fencing I 1 *The debris will be disposed of at: `t Location of Facility I declare under penalties of perjury that the statements betein 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 lice s aid for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: ] �a b�� e. Date: 9 Owners Signature(or attachment) Date: Approved By: Date: Building Official(or ,nee EMAIL ADD S: Zoning District: Historical District: _ Yes No Flood Plain Zone:'•_ Yes = No Water Resource Protection District: Within 100 ft.of Wetlands: IT Yes No Yes No The Commonwealth of Massachusetts Department of Industrial Accidents '''I-- : Office of Investigations • �= 1,--ii = •t„' Lafayette City Center `' 2 Avenue de Lafayette, Boston,MA 02111-1750 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Anulicant Information Please Print Legibly Name(Business/Organization/Individual): e- Q v6= 14e, ___ Address: E. City/State/Zip: I j1 lQ a K 0 S Phone#: 3o 5o4 4:0 Are you an employer?Check the appropriate box: Type of project(required): 1.g I am a employer with ci 4. 0 I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g- 0 Demolition working for me in any capacity. employees and have workers' $ 9. ❑Building addition [No workers' comp.insurance comp.insurance. 10.0Electrical repairs or additions required.] 5. We are a corporation and its p 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 l2 Roof repairs insurance required.]t c. 152,§1(4),and we have no employees. jNo workers' 13.0 Other comp.insurance required.] I *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. f ,.�� r'. Insurance Company Name: IA Cka Z Policy#or Self-ins.Lic.#: 6 $.3 614D S6O 22 Expiration Date:.6 e( '2P23 Job Site Address: VD'S 5D. & .4)41 : . -1-1 City/State/Zips. •Q•,M T1 OA beiloY 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 ag tinst 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. i.Signature: % Date: 1'1fi I . _ Phone#: 44 41640t 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): 1OBoard of Health 20 Building Department 31:1City/Town Clerk 4.0Flectrical Inspector 5.0PInmbing , Inspector 6.DOther Contact Person: Phone#: AC®R®° CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) ls...---- 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 (a°NNo,EA)_ (508)775-1620 1 FAX 'Ala ADDRESS: Iullivan@doins.com 973 IYANNOUGH RD INSURER(S)AFFORDING COVERAGE NAICE HYANNIS MA 02601 INSURER A: ACE AMERICAN INSURANCE CO 22667 INSURED INSURER B: i KELLY ROOFING INC INSURERC: INSURER D: 8 RHINE RD INSURERE: YARMOUTHPORT MA 02675 INSURER F: COVERAGES CERTIFICATE NUMBER: 775626 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 LIMITS ADDL SUER' i POLICY EFF POLICY EXP LTRI INSR WVD I POLICY NUMBER i(MMIDD/YYYY)I(MM/DD/YYYY) COMMERCIAL GENERAL LIABILITY I EACH OCCURRENCE i S f ( DAMAGE TO RENTED $ CLAIMS-MADE OCCUR PREMISES(Ea occurrence) MED EXP(Any one person) $ N/A PERSONAL BADVINJURY I$ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ I POLICY JECT I LOC PRODUCTS-COMP/OP AGG $ i I OTHER: I I$ 1 AUTOMOBILE LIABILITY I 1 j I COMBINED SINGLE LIMIT 1$ t(Ea accident) ANY AUTO I BODILY INJURY(Per person) $ — ALL OWNED I SCHEDULED AUTOS N/A BODILY INJURY(Per accident) $ AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS (Per accident) I I$ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB 1 CLAIMS-MADE . N/A AGGREGATE Ts J ,DED I RETENTIONS �/ 1$ WORKERS COMPENSATION 1 X 1 STATUTE I 10RH_ I AND EMPLOYERS'LIABILITY ANYPROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $ 500,000 A OFFICER/MEMBER EXCLUDED? N/A N/A N/A i 6S62UB8H08580922 05/10/2022 05/10/2023 1 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE'$ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below I E.L.DISEASE-POLICY LIMIT_$ 500,000 N/A • f I 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 U3 'c- KELLY ROOFING PH. 508 509 4640 8 Rhine Road MA C.S.L. #099167 Yarmouthport MA H.I.C.R. # 128957 MA 02675 INSURED July 23, 2022 Proposal submitted to The Owners of 135 South Shore Drive, South Yarmouth MA. We propose to supply all materials and labor required to remove and replace the existing asphalt roof on tlie Unit al/27 properties at the address above Protect all walls, Windows, shrubs, plants etc. during roof strip. All debris to be removed to town transfer. Install Aluminum 8"White Drip Edge On All Eaves 5" White Drip Edge to be installed on all Rakes. 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 Specified. 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. Repair 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. Obtaining of Town Building Permit. At a total cost of$3,500 For Unit 10A ` At A Total Cost Of $6,250 For Unit 26/27 Building Payment Schedule; Balance upon Completion Proposal Submitted by: Oliver Kelly Proposal accepted by: `'Nt Date. 9 /28 /2022 • Commonwealth of Massachusetts iNpri« Division of Professional Licensure Board of Building Regulations and Standards Construction 31 plehvispr Specialty CSSL-099167 Expires:09/28/2023 OLIVER M KELLY 8 RHINE ROAD $ # YARiWOUTH FNIRTMA 02675 -- • • Commissioner dua f OP ro/22W22c%WC,Lec//J(o �ga-,),..)/a C44e47/-.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 v 20M-05/17 .%7T U!/l///'%ice .,—•••irk /' Office of Consumer Afrthrs&gusmess f u it 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 06/13/2023 1000 Washington Street -Suite 710 OLIVER KELLY Boston,MA 02118 OLIVER M.KELLY �� n�O B RHINE RD. ,sf l-�. .4- YARMOUTHPORT,MA 02675 Undersecretary Not valid without signat re