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HomeMy WebLinkAboutBLD-22-007248 po 0I,7/2Z Office Use(Jul., 0y + . y� Amount_ SO OD L MAV►i.. 4 Permit expires 180 days from . issue date 6i,b - aa - 6072M EXPRESS BUILDING PERMIT APPLICATIONR E G E I V E D TOWN OF YARMOUTH Yarmouth Budding Department JUN 15 2022 1146 Route 28 South Yarmouth, MA 02664 -_-_ -__ (508)398-2231 Ext. 1261 BUILDING DEPARTMENT CONSTRUCTION ADDRESS: SPel-Zea_ 270 x. 206 S7. t°( ._AIY —J ASSESSOR'S INFORMATION: Map: Parcel: 1 C OWNER 9yt{,fL.l.Lej 4'IL 1.13-ti __- 6�< 4_ _S�C�. NAL: f (I SENT ADDRESS T EL. # CONTRACTOR:IkeLLM d4,13c Q Y t fW tt'l IAA- ©2-eoS NAME MAILING ADDRESS TEl TO So (ibLtO Residential OCommercial Est.Cost of Construction S�- _ 18 7 a Home Improvement Contractor Lie.as /A G S 7 Construction Supervisor Lic.# ©at 41 t o7 _ Workman's Compensation Insurance: (check one) � 0 I urn the homeowner ❑ I am the sole proprietor 0 1 have Worker's Compensation Insurance Insurance Company Name: 4C 414412 LC.W J +Worker's Comp.Policy# 6S 62i)tg 8-1167 v Q�d e 7-t9 2 WORK TO BE PERFORMED Tent L Duration _ (Fire Retardant Certificate attached?) • Wood Stove LI Siding: #of Squares Replacement windows:# Replacement doors: # Hooting: #of Squares 2'7 (remove existing*(max.2 layers) Insulation n I I Old Kings Highway/Historic Dist. Replacing like for like Pool fencing n *The debris will be disposed of at: � W J its• +V.r't7/L Location of Facility I declare under pcnaltic • per'ury that the statements here' c , ed are true and correct to the best of my knowledge and belief. I understand that any false answer(s) will be just cause for, •• rL'canon of m license, pros cation under M G I.('h.268,Section I Applicant'sSignaturc. - ' �� • ` - 6 � 0 ,2 ��/� � j/ Date: Y� [iJ /'Owners Signature(or attachment) �(i! /'1 iL.. Date: 6 • 1- 22 Approved I3y. Al — _ Date e'/ *"---- Building Official(or • we EMAIL ADDRG ' -- Zoning District: Historical District: Yes No Flood Plain Zone: Yes No Water Resource Protection District: Within 100 II.of Wetlands: Yes No Yes No The Commonwealth of Massachusetts ,� 1. Department of Industrial Accidents = 1= 1 Congress Street,Suite 100 J=`efiF= Boston,MA 02114-2017 \ .� i / www.mass.gov/dia up Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Or anization/Individual): `•• w - L• C- Address: Li.ovi, LAD City/State/Zip it ti -c1. P)!% i 1�j' Phone#:52..)S t L{(041 t� Are you employer?Check the appropriate box: Type of project(required): l. I am a employer with ( employees(full and/or part-time).* 7. 0 New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. D Remodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.] 9. ❑Demolition 10 0 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 11.0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.n I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.El ROOF repairs These sub-contractors have employees and have workers'comp.insurance.= 6.0 We area corporation and its officers have exercised their right of exemption per MGL c. 14.0 Other 152,§t(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 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 iding workers'compensation insurance for my employees. Below is the policy and job site information. nn __ 1-kitzaLcA-ki Insurance Company Name: CW Pol' y#o elf ins.Lie.#:�C1 v`V \j tJS S5 Or? Expiration Date: `.. ° [0 ' G� Job Site Address: 6 �q.t.T&"x ICJ. City/State/Zip: 11/42044400-if `" ©�`�6�ty p; 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 ender the pains and penalties of perjury that the information provided above is true and correct. Signature Date: & 10 Phone#: bQ r 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#: AC'(RO® CERTIFICATE OF LIABILITY INSURANCE DATE(MMlDDr'YYY) �-� 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'NEJL INSURANCE AGENCY PHOmic,"N,Ezt): (508)775-1620 F c,Na): ADDRESS: Isuliivant 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 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. LT TYPE OF INSURANCE 1N pip POLICY NUMBER ,(MM/DDY/YYYY) IMM/DD/YYYY), LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE OCCUR 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: _ $ COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY (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 I RETENTION$ $ WORKERS COMPENSATION X I PER OTH- AND EMPLOYERS'LIABILITY Y/N (STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,000 A (OFFICER/MEMBER EXCLUDED? 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 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 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 �Pi g7o2no/7/ oea7iL-/G' 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 0 20M-05/17 . it/iI/1,/Y!//,e(L./� �// /i/-i iiii/ . . Office of Consumer fta us'$�0Laif ess f u Mtion 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 iQ(31-CP �UU 8 RHINE RD. ls�''��%ice` YARMOUTHPORT,MA 02675 Not valid without signet re Undersecretary • • Commonwealth of Massachusetts ±� Division of Professional Licensure Board of Building Regulations and Standards Construct o0,1 I414Spr Specialty t< CSSL-099167 I cpires:09/28/2023 OLIVER M KELLY ,*, 78 RHINE ROAD ,-; YARMOUTH P9RT MA 02675 ` frf. Commissioner and fi. UUiia. •