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HomeMy WebLinkAboutB-13-842ov F. TOWN OF YARMOUTH Building Department BUILDING (508) 398-2231 a .1261 � PERMIT NO �- B-13-842. s• ISSUE DATE PERMIT _ _ APPLICANT ............................ JOB WEATHER CARD PERMIT TO : Repalr IAT (LOCATION) 10029NIGHTINGALE DR ZONING DISTRIC R-40 Bldg. Type: Residential I SUBDIVISION MAP LOT BLOCK 1088.182 BUILDING IS TO BE: CONST TYPE 5•B USE GROUP R-3 LOT SIZE Re -roof: 20 sqs.; Stripping old shingles REMARKS AREA (SO FT) EST COST ($ $6,000.00 PERMIT FEE ($) $35.00 OWNER IHAYES, FLORENCE M BUILDING DEPT BY ADDRESS PHONE CONTRACTOR LICENSE 99187 Kelly, Oliver 8 Rhine Rd Yarmouth Port MA 02675 5087754498 INSPECTION RECORD FIELD COPY Date Note Progress - Corrections and Remarks Insoector • • unke use unty ~�YqR3'8 Permit r OH Feet : w..' Pemttt expires 6 months from issue date. r EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: ASSESSOR'S INFORMATION: OWNER: Map: Parcel: NAME PRESENT ADDRESS CONTRACTOR: ut-w sir- 116 Wn , NAME hIAMO ADDRE /SS Residential ✓ Commercial TEL 0 TEL e 0 Est Cost of Construction Ilome Improvement Contractor Lia i_ IZ$°15�% Construction Supervisor Lie. Workman's Compensation lasurrnce: (check one) / I am the homeowner I am the sole proprietor ,(q_{ 1 have Worker's Compensation Insurance ✓ Insurance Company Name: _L/ �✓(,rQiTs/ /�"/�.�— " ` Worker's Comp. PolicyN i-J(,Z 153316 f50Ci OZ/ }YORK TO BE PERFORMFD 11 Tent (Foe Retardant Certificate attache)) 0 Wood Stove shed - 0 Siding: a of squares C Repluement wiadaws; o C Replacement dans: I) vg' roof. 0 of Syuam 2o �(�, 7 lasutatioa s i S PPing old shinglcs' () going over layers of existing roof ❑ Old Kings W ghway/tilstork District . I _. Raormg/Siding (IJke for like) F—W 97be debris will be disposed of I declare under penalties wiu bejust rause fa deg Applicant's Owners Signatury (or Facility bereia contained are true and C91GZi`k the bat of my knowledge and belief. I understand that any false aaswer(s) e no for phjhsecutlon UPGVjUL CV. 268. Section 1. Approved By Due: Building Official (or daigoee) _la - I -`Ls l Zoning Dlstriet: Historical District Yes No Flood Plain Zone: Yes No Water Resource Protemon District: Within 100 R of Wetlands: Yes No Yes No DEC 13 2012 U -r�Saq� �rS i+.uunuir_n el 77se Commonwealth ofMassaehusetts Department oflndustrial Accidents office oflnvestigations 600 Washington Street Boston, MA 01111 www.massgov/dla Workers' Compensation Insurance Affidavit: Builders/Contractors/Electddans/Plumbers AY)T)Hcant Information Please Print Leeibly Name(Business/organization/individual)• ©t,tyi iL (.CratJL?� City/State/Zip: g ja L&� PQZ;'- KA O.Xb l -q- Phone #:�Fin*o 45-jc)W %A I514t:) Are u an employer? Check the appropriate box: Type of project (required): l.;?I I am ato er with. �P y _. 4. ❑ 1 am a general contractor and I 6. Now construction employees (full andtoi part-time).* 2.0 1 am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet 7. ❑ Remodeling ship and have no employees These sub -contra= have S. 0 Demolition working for me in any capacity. to ees and have workers' � y 9. • ❑Building addition (No workers' comp. insurance required] comp. insurance.= 5. ❑ We are a corporation and its- 10.0 Electrical repairs or additions 3. [:11 am a homeowner doing all work officers have exercisedI LO Plumbing repairs or additions myself. [No workers camp. right of exemption per MGL Q'�tooftepairs insurance require&] t t:.152, § 1(4), and we have no 13.0 Other employees. [No work=' eorM. insurance required.] -Any appliant ant cheeks box #1 tout also fill out chs section below Aawina lb& worker' eompen adon poUry ft&rFadm. t Hgmcgwnas who sabuit d& sffidavkt andiradnY gay sm doing all weekend dm hire uusida coattacWrs mat a+bndt a asw af$dnrit lndiadng ouch tcannuaeem dutchecte this box ,rant amelud an a"donal sheet showing Ute tome of chs subcorraactor and stats whether or not thea endties bave employees, if the subowutractors have ea*loyea, they taut praywa their workers' comp. policy number. lam an employer that rsprovidlng workers' compensation lnsurancefor my employees Below is the poUty and job sits ir{Jormation. Insurance Company Name Lt L'-,�Yi nNt try 4a. Polity # or Self -ins. Lic. M t L 0-12-3 t S161b"A S 04 (32 1 21Expiration Date: 12.2.$ • 2012 Job SitaAddreugr �k6Q IKkirA� Z so - City/5tatemp: Mt,* 02-&(0 � Attach a copy of the workers' compensation policy declaration page (showing the policy. number and expiration trate). Failure to secure coverage as required under Section 25A of MOL e.152 can lead to the imposition of criminal penalties of a fine up to S1,500.00 andlor 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 insivance coverage verification. I do hereby certify under the pains and penaiiies ofperjury that the information provided above is true and correct, Offl c a use only. o not write area, to a comp y or town ofJktai City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. CitylTown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #• r • + � �� �ly�%7i%%7ia%7iuiPi�iY/(//'(/ t%���i���(�GW�'�ai�.�ULGU'P/rJt:�' Office of Consumer Affairs and Buslnesg; Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration ReglWatlon: 128957 Type: Individual Wration: 6/14/2013 TriF 2 Oliver Kelly Oliver Kelly 8 Rhine Rd Yarmouthport, MA 02675 ' Update Address and return card. Mark reason 1 C] Address [] Renewal 0 Employment C soAs a eau -Wil G17e �aururornr-0rr�� r•/ : f�crwrr�u:c!/l 0111ce of ConsumerAffairs & Basindcss Regulation ME IMPROVEMENT CONTRACTOR eatstration: 126957 Type: piratlon:: 6!1412013 Individual Oliver Kelly Olivet Kelt' 8 Rhine Rd. Yarmouthpod, MA 02675 Undusecretary License or registration valid for individul use only before the ezplratlon date. If found return to. Office of CoosumerAffairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, MA 02116 Not valid without signature 91a..>uchu.rtt. - Drparnncnt ur Public Citret� rt3nard nr Buildin ; RegulatGro:. untl Stantlard • license: CS SL 99167 Restricted to: RF,1(VS •OUVER KELLY 8 RHINE ROAD YARMOUTHPORT, MA 02676 Expiration: 91262013 ( •omw6 -nor Tri 5155 , .10812011 FRI 14;05 FAI 508 7781818 DOALING & WNJINS -'1001l001 :032 91112137 >w 487 (0148.8) ?PAD i{s•uzaaolivl8lons.uom-zvs 35087781218 Sage: 3 of 3 CERTIFICATE OF LIABUN INSURANCE I„��,,, !>ftil8n Ae A W17aR O1* ONLY AM COMMOM W 1p�iRiM Wau MW CMiRQATiK*L=L 100 atT1lLCATa "n MOT A!¢OYAT1Y r pR MIQATa my A-MM6 mmufa oR !� "a calm"a A11a = aY I= Mzw WSWe 'XHW ClRr MATH OF DIa1WLNCa 0083 NOT OONai MaS A Maw” ousu a 71a "M laa>eli in AUmaw aRSU WATJ".ORE+RODUC9KAUDIO0101WATIHMDelt _ ®7ifiiW7Y AbVRY YIiRrN11A111Y1�. 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