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HomeMy WebLinkAboutBLD-23-001769 {j Ufa% PIA / 0 ` f'2-.? Office Use Only ,� �'~ t I . .4fA g w*rr n c:E_ t.# �^�-O'� / t} Permi3''1 Amount Permit expires ISO days from issue date !LJD--: -C ; E : E l v E D EXPRESS BUILDING PERMIT APPLICATI " _ TOWN OF YARMOUTH OCT 03 2022 Yarmouth Building Department H46 Route 28 gU1LDING DcPARTMENT South Yarmouth, MA 02664 9Y - _ &e— &--14-- (1\J. ' q. %Oil (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: iir L4 L-�� ASSESSOR'S INFORMATION: Map: Parcel: OWNER: - 'iLvkA PATTRJ't `� e P PRESENT 11 WG s i °- t} tJLCJ7 PRESENT ADDRESS ll ��" EL. # r CONTRACTOR: t' ` -' ,-..-! kf-i c` C--a`,j OA i\:l:e. L ) i\-ukt,),)riA;'::,,cs tA"\; o2. i (c NAME MAILING ADDRESS r TEL.# t ®Residential 0 Commercial Est.Cost of Construction$ $SS0 Home Improvement Contractor Lic.# l2'o i S f Construction Supervisor Lic.# t t I ' % Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor I have Worker's Compensation Insurance Insurance Company Name: C Alf aC.1�,{,v t- r •te ; F -, Worker's Comp.Policy#b-; L Ca :3'1«.I) :3 c I ;% WORK TO BE PERFORMED Tent El Duration (Fire Retardant Certificate attached?) Wood Stove 0 Siding: #of Squares Replacement windows: # Replacement doors: # Roofing:A of Squares 2-0 (0-) (max.( )Remove existing* layers) Insulation I I 2 n Old Kings Highway/Historic Dist. qj Replacing like for like Pool fencing 11 *The debris will be disposed of at: +�+ `'>,.2''"-"ti I..0-4-0,-.:3"-....-;C:r--X. t'i Location of Facility I declare under penalties of perjury that the statements herein contai , 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 cation of my license and f. 1 , ion under M.G.L.Ch.268,Section 1. Applicant's Signature: ( L Date: 0 3 ^� Owners Signature(or attachm i Date: `0 • 3 - Approved By: Building Official(or design EMA :ADDRESS: Date: ��J � Zoning District: Historical District: Yes No Flood Plain Zone: `__ Yes _ No Water Resource Protection District: Within 100 ft.of Wetlands: Yes No Yes No _ The Commonwealth of Massachusetts } 161._ Department of Industrial Accidents �'el= 1 Ceisgrecs Street, Suite 100 =':i— Boston, MA 02114-20X 7 i�.■ www.mass.gov/dig Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information . Please Print Legibly i Name (Business/Org ,lation/Irtdividuaij: - i k--1--` \( c,;k j ud J. Y._) / rAddress: �1��`U i• �'�.1��2•IV City/State/Zip: c"u\iQO(A )4l1 Ph ne #: J`� � 9 ` b�{0 Are you an employer?Check the appropriate box: Type of project(required): 1.211 am a employer with t employees(full and/or part-time).* 7. E New construction ..0 I am a sole proprietor or partnership and have no employees working for me in any capacity.[No workers'comp.insurance required.] 8• Remodeling ` 3.E I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9 C. Demolition 4.0 I am a homeowner and will be hiring contractors to conduct all work on property.mY I will 10 C Building addition • ensure that all contractors either have workers'compensation insurance or are sole 11.11 Electrical repairs or additions proprietors With no employees • 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet 12.n Plumbing repairs or additions These sub-contractors have employees and have workers'comp.insurance.i 1 -[goof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no employees. [No workers'comp.insurance required.] *Any applicant that checks box 41 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 outride contractors must submi?.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 pro 'ding workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: - , ,NaC,iU3 Policy#or Self--ins.Lic. #: �C.J ; u-s h 1 t, B 5- ? _ '�`" "� U expiration Date: cS " 0 , �-_ Job Site Address: Cw\ic ..--. LA-0 City/State/Zip: . icl-a-Kekt ;J'f (0 Z 67 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiratio 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 S250.00 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 certify under the gins and penalties of perjury that the information provided above is true and correct. / Signature:-b. L.<N i /0 �'> Date: / 0 / �.._/_ Phone#: c '�, LI —4/0 ( 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. ElectricaI Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: Commonwealth of Massachusetts -I- Board Division of Professional Licensure Board of Building Regulations and Standards Construction:etiri6Vispr Specialty t CSSL-099167 E3cpires:09/28/2023 OLIVER M KELLY . f 8 RHINE ROAD -110 YARMOUTH PORT MA 02675 �- 1 0 1Y Commissioner %AA I. Cvnck� �J P 9/22/22GtfZCG��CGGC � �/G'CJCl1��G1� ?CG Pf 1 Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Individual VER KELLY Registration: 128957 OLI 8 VER Expiration: 06/13/2023 YARMOUTHPORT, MA 02675 • Update Address and Return Card. SCA 1 C' 20M-05/17 / Office of Consumer Af iirs&Business 1figur 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 C0,18 RHINE RD.YARMOUTHPORT,MA_02675 Undersecretary Not valid without signatre ,3 CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) A R 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 DOWLING &O'NEIL INSURANCE AGENCY NAME: Linda Sullivan I FAx PHONE (Am.No.Ext), (508)775-1620 (A/C,No): %MESS: T u l l iva n @d o i n s.co rn 9731YANNOUGH RD INSURER(S)AFFORDINGCOVERAGE NAIC#HYANNIS MA 02601 INSURER A: ACE AMERICAN INSURANCE CO 22667 INSURED KELLY ROOFING INC INSURER C: INSURER : INSURER D: 8 RHINE RD INSURER E: YARMOUTHPORT MA 02675 INSURER F COVERAGES CERTIFICATE NUMBER: 775627 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. INSR ADDL SUBRI POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD wVD 1) POLICY NUMBER (MNWD/YYYY) (MM/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: POLICY PRO- GENERAL AGGREGATE $ JECT LOC PRODUCTS-COMP/OP AGG $ $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ _ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS N/A SCHEDULED AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED AUTOS PROPERTY DAMAGE $ (Per accident) $ UMBRELLAUAB OCCUR EXCESS LIAB EACH OCCURRENCE $ CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ WORKERS COMPENSATION $ AND EMPLOYERS'LIABILITY YIN I STATUTE 1 ER ANYPROPR IETOR/PARTNER/EXECUTI VE A OFFICER/MEMBER EXCLUDED? N/A N/A N/A 6S62UB8H08580922 05/10/2022 05/10/2023 E.L.EACH ACCIDENT $ 500,000 (Mandatory in NH) If yes,describe under E.L.DISEASE-EA EMPLOYEE $ 500,000 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/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 Town of Falmouth ACCORDANCE WITH THE POLICY PROVISIONS. 59 Town Hall Square AUTHORIZED REPRESENTATIVE Falmouth MA 02540 C` Daniel M.Cr o 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 AC� R C� DATE MM/DDdYirYY) 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 CONTACT NAME: Linda Sullivan DOWLING & O'NEIL INSURANCE AGENCY PHHO"N ); (508)775-1620 FAX E-M(A/CAIL (NC,No): ADDRESS: IsuIIIVan@doins.com 973 IYANNOUGH RD INSURER(S)AFFORDING COVERAGE NAIL# HYANNIS MA 02601 INSURER A: ACE AMERICAN INSURANCE CO 22667 INSURED INSURER B 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 ADDL SUBR LTR TYPE OF INSURANCE INSD VD POLICY NUMBER POLICY EFF POLICY EXP (MM/DD/YYYY) (MM/DD/YYYY) LIMITS W COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE I O RENf ED 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: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED AUTOS PROPERTY DAMAGE $ (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ WORKERS COMPENSATION $ AND EMPLOYERS'LIABILITY Y/N X STATUTE ERH ANYPROPRI ETOR/PARTNE R/EXECUTI VE A OFFICER/MEMBEREXCLUDED? N/A N/A N/A 6562UB8H08580922 05/10/2022 05/10/2023 E.L EACH ACCIDENT $ 500,000 (Mandatory in NH) If yes,describe under E.L.DISEASE-EA EMPLOYEE $ 500,000 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/lwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULDTHE EXPIRATIONDATTE ABOVE DESCRIBED NOTICE POLICIES WILL BE C R DELIVERED THEIN Town of Dennis ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 2060-485 Main Street AUTHORIZED REPRESENTATIVE South Dennis C, MA 02660 Daniel M.Crowley,CPCU,Vice President—Residual Market—WCRIBMA ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD CORPORATION. All rights reserved.