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HomeMy WebLinkAboutBLD-22-007247 C CU,c. tit.i itS lit .OF.YAK n / p f 17 j Z)Z. Office Use Only /� {r� �' �/ V` ! Pennit# l-ev+�,+'/ 0 Amount.- 50 by CA,,, Nwn. n CS 'x "Canal*c,e • Permit expires 180 days from issue date £-D._Z0 -nvw-q•--/ EXPRESS BUILDING PERMIT APPLICAT E C 1 V E D TOWN OF YARMOUTH Yarmouth Building Department J�N 15 a2� . 1146 Route 28 South Yarmouth,MA 02664 gIJILDING DEPARTMENT (508) 398-2231 Ext. 1261 By: CONSTRUCTION ADDRESS: 1 VU (1.16)—X I`the.. t (/) x YY� r' ; n, _ ; ;;13 ASSESSOR'S INFORMATION: �n Mapes 1 i �� ! Parcel: l p� j� /�`� OWNER? E Ci lL. f u rat). ek/ i1 t tic A L, %nt'� ( 1 yiatiiiitii7_ �1\ 03-6) �1NAME PRESENT ADDRESS TEL. # t CONTRACTOR: 1/c C L.eZ IW-Q$,t l G- % 12.u..,,ta 4•`OrL r WV IJ(4- 1Lj }(, Li i NAME MAILING ADDRESS TEj�,#_ % S 0 9 4640 Residential ❑Commercial Est.Cost of Construction$ 37 O 0 Home Improvement Contractor Lic.# (2$-`$7 Construction Supervisor Lic.# 0 9 -1 ! 1,7 Workman's Compensation Insurance: (check one) ❑ I am the homeowner 0 I am the sole proprietor IEKave Worker's Compensation Insurance //�� Q Insurance Company Name: i �'T'v4 .I C� Worker's Comp.Policy# 656 2 U/J 8 ko g 5 09 22 WORK TO BE PERFORMED n Tent 0 Duration (Fire Retardant Certificate attached?) Wood Stove I 1 Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares g (lRemove existing*(max.2 layers) Insulation J l Old Kings Highway/Historic Dist. CI)Replacing like for like Pool fencing _ .. 'The debris will be disposed of at: ttt`�T� "Q14JV s G •`� Location of Facility I declare under penalties of perjury that the statements herein contained are true and correct to the best of my knowledge and belief. I understand that any false answer(s) will be just cause ford or c on of my!Mak..r prosecution under M.G.L.Ch.268,Section 1. eq0 ' 2 _ Applicant's Signature., Date: /* r Owners Signature(or attachment) !? I Date: 6 j. / Approved By: ` 7 2 Date: /� . ���1x Building Official(or gne EMAIL ADDRESS: Zoning District: Historical District: - Yes No Flood Plain Zone: Yes No Water Resource Protection District: Within 100 ft.of Wetlands: Yes ` No :_ Yes ..:' No _ The Commonwealth of Massachusetts 5 1, Department of Industrial Accidents E.1 1 Congress Street,Suite 100 t'. it:14 Boston, 024 wwrv.MAmass.gov11/dia-2017 Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly t4. r Name (Business/Or anization/Individual}: t, ]Cr ` " Address:(5 (AINZ LAD L() City/State/Zip r'\YD2OP_v , (A k5$ Phone#:5 cR `-{(p({'0 Are you employer?Check the appropriate box: Type of project(required): 1. I am a employer with ( employees(full and/or part-time).* 7. ❑New construction 2.01 am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.❑i am a homeowner doing all work myself.[No workers'comp.insurance required.]° t0❑Building addition 4.❑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.❑Electrical repairs or additions proprietors with no employees. 12.Li Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. ROof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,*i(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#I 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 pro idring workers'compensation insurance for my employees. Below is the policy and job site information. _ Insurance Company Name: �--� 4k/1,6424c/4-NJ,. _Policy#or Self-ins.Lic.#:` D5`U 2_0 iS\vS Q9� Expiration Date: ° L 0 ° -- I ICSt:6 I2 14 City/State/Zip:!/v' 4241O.1'17' ^ ��7-3Job Site Address: I� , 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 here erti rider the pains and penalties of perjury that the information provided above is true and correct. , ( Signature Date: 10 ( '3 7 Phone#: v-�S SE) t 46140 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): 1. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: AcoRD® CERTIFICATE OF LIABILITY INSURANCE DATE(MMlDDmYY) 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 P tio.E:tl: (508)775-1620 Fax (A/C,No): ADDRESS: (Sullivan@doins.com 973 IYANNOUGH RD INSURER(S)AFFORDING COVERAGE NAIC# HYANNIS MA 02601 INSURER A: ACE AMERICAN INSURANCE CO 22667 INSURED INSURER B: KELLY ROOFING INC INSURER C: INSURER D: 8 RHINE RD INSURERS: 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 ADDL SUER POUCY EFF POLICY EXP LTR TYPE OF INSURANCE _INSD Wvo, POUCY NUMBER (MM/DD/YYYY) (MMIDD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL BADVINJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ PRO- POLICY JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED 'SCHEDULED N/A BODILY INJURY(Per accident $ AUTOS AUTOS ) NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per accident) • UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED } RETENTIONS WORKERS COMPENSATION X STATUTE ! ERH AND EMPLOYERS'LIABILITY Y/N ANYPROPRIETOR/PARTNER/EXECUTIVE 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) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT,$ 500,000 I I N/A 1 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 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 Daniel M.Crowley,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 26(2014/01) The ACORD name and logo are registered marks of ACORD Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards ConstructiotrSilt Viapr Specialty CSSL-099167 Expires:09/28/2023 OLIVER M KELLY • 8 RHINE ROAD YARMOUTH PORT MA 02675 -- + "/ Commissioner eAd f. 4ncjia, „d7le ro/- 2- w2mt/- 4-toeiio/-- ///ea),)a(4)-el/..)- 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 C: 20M-OS/17 Office of Consumer Af{ors&Business x6s 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 n 4V? 8 RHINE RD. YARMOUTHPORT,MA 02675 Undersecretary Not valid without signat re