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HomeMy WebLinkAboutBLD-23-005990 C WILLA 5--/`2'7 • pF'YA4 RECEIVED Office Use Only _�-- �_ _ ny393 A. f t,y IC 0 Permit# to • ° �'A nit - y; APR 27 2023 Amount ��, ? ,, -•'$t l' Lam ,• BUILDING DEPARTMENT Permit expires 180 days from [iy --- -__-- issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 126, i)a C CONSTRUCTION ADDRESS: L/ \)�� ��'c."11- - - �Jsl�S�.J►��„( ASSESSOR'S INFORMATION: �1 Map: 26 Parcel: 7 3. L W ONER: S/ ()-Prpl .- O0+ar a 2-v6 SD. S-Le QQ, So. "t 42a ivu-s-t4 41 02b61-1 NAME (n� PRESENT ADDRESS TEL. # 5 - 2 i-O 7` 71 CONTRACTOR: 0L� �r Q 1VJ4: WO - L AA 026-1S NAME MAILING ADDRESS TEL.#$( $0Q.Li bL/'O filResidential ❑Commercial Est.Cost of Construction$ /4/t q0i Home Improvement Contractor Lic.# /2.$93 Construction Supervisor Lic.# O /62 Workman's Compensation Insurance: (check one) ❑ I am the homeowner 0 I am the sole proprietor ❑ I have Worker's Compensation Insurance Insurance Company Name: 4C4. 441,e .Z1 (,y¢A) Worker's Comp.Policy# 6 56206 /--/08-53 WORK TO BE PERFORMED Tent II Duration (Fire Retardant Certificate attached?) Wood Stove El Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares 3O ( • )Remove existing*(max.2 layers) Insulation El 1 1 Old Kings Highway/Historic Dist. CI)Replacing like for like Pool fencing n *The debris will be disposed of at: 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 causeo fordenial or revocatio, . , y license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: a; 1414107 � ., Date: 4/ / 27 1 2.3 Owners Signa re(or attachment Date: Approved By. #4 Date: _/ 23 Building Official(or designe,- MAIL ADDRESS: Zoning District: Historical District: Yes No Flood Plain 7one: Yes No Water Resource Protection District: Within 100 ft.of Wetlands: Yes No Yes No Office of Investigations � i'► 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): Address: S €, LA-t. City/State/Zip: &?ivoz4 c`L(,PE,2c 14t Olki7S Phone#: $pit LL 104.-0 •Are/you an employer? box: Type of project(required): 1.1110 Iamaemploy ■ �� general randI 6. New employees( ,� sub-contractors ❑ construction 2.❑ I am a sole p ' on r eet. 7. ❑Remodeling ship and have have 8. El Demolition working for e��• workers' 9. ❑Building addition [No workers' comp. m required] ■ •t. • ,d its 10.0 Electrical repairs or additions 3.❑ I am a home : . officers I their 11.0 Plumbing repairs or additions myself. (No L :a • exemption GL 12.©Roof repairs insurance re t have no 13.0Other employees. ' yam..insurance .d.] *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. Insurance Company Name: AC,EiA Policy#or Self-ins.Lic.#: (5(02u,6c6 trtO S555 Dat Expiration Date: 5• to-?_� Job Site Address: % 54 c.'at ‘Oe_- City/State/Zip: 30- `1 ?0117`7' tq°f ®Zbo y 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 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 pedury that the information provided above is true and correct. Signature: 0- Date: 2 / 2 O 2 3 Phone#: So S 501 Ltbkto 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): 1❑Board of Health 20 Building Department 3L]City/Town Clerk 4.0 Electrical Inspector 5Llumbing Inspector 6.DOther Contact Person: Phone#: e 6/74/74o-/-moedio-//ga4c)ac4c)-6/40" . 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. CA 1 0 20M-05/17 Office of Consumer l�tf irs 8 BuslrnessrKg raation 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 ///1 8 RHINE RD. a Not valid without si nattr)—( �lre YARMOUTHPORT,MA 02675 Undersecretary 9 • ,�. Commonwealth of Massachusetts • (��j� Division of Professional Licensure Board of Building Regulations and Standards Constructir Specialty CSSL-099167 J 6c�pires:09/28/2023 OLIVER M KtgLY 2 ... 8 RHINE ROAR -�. YARMOUTH %IR Mom^\ 0 CW Commissioner raa fi? , ACOREP CERTIFICATE OF LIABILITY INSURANCE DATE CERTIFICATE 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 Ileu of such endorsement(s). PRODUCER CONTACT NAME: Linda Sullivan DOWLING & O'NEIL INSURANCE AGENCY PHONE (A/C. (508)775-1620 FAX (A/C, E-MAIL ADDRESS: isullivan@doins.com 973 IYANNOUGH RD INSURER(S)AFFORDINGCOVERAGE 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: 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 !ADDLiSUBR POLICY EFF POLICY EXP I LTR INSD VD POLICY NUMBER IMM/DD/YYYYI (MM/DD/YYYY) LIMITS W COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE J OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY 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 V PER OTH- AND EMPLOYERS'LIABILITY Y/N /N. STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,000 A OFFICER/MEMBEREXCLUDED? N/A N/A N/A 6S62UB8H08580922 05/10/2022 05/10/2023 (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/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 Lakeville ACCORDANCE WITH THE POLICY PROVISIONS. 346 Bedford Street AUTHORIZED REPRESENTATIVE Lakeville MA 02347 C Daniel M.Cro rney,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ( ) The ACORD name and logo are registered marks of ACORD ORD CORPORATION. All rights reserved. ACORD 26 2074/01 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 April 10, 2023 Proposal submitted to Ms. Sandra DiGiovanni Of 278 South Shore Drive, South Yarmouth MA. We propose to supply all materials and labor required to remove and replace the existing Asphalt Roof at the Address Above Protect all walls, Windows, shrubs, plants etc. during roof strip. All debris to be removed to town transfer. Retain Existing Vented Drip Edge, 5" White Aluminum Drip Edge to be installed 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,ln All Valley Areas,Over Complete Rear Dormer Roof and around all protrusions. 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$14,500 For Landmark Pro Shingles Add $700 Proposal Submitted by: Oliver Kelly Proposal accepted by.r'.1 '2I Date. 47 / ' ' /2023 Best Contact Phone is y 5��- pc, -79 7 This proposal is valid for 30 days from date above, please call to verify thereafter.