The URL can be used to link to this page

Home My WebLink AboutBLD-19-000835 OT YAR ;Office Use Only t0. 'Permit# 3 *„�r e 4 Amount . '—' ed' - !Permit expires 180 days from ;issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 ,Q�4l (508)398-2231( Ext. 126_%1y S • CONSTRUCTION ADDRESS: 70 e rAve /Ann A.74G' 0abey ASSESSOR'S INFORMATION: • Map: `7 Q /tut y OWNER: Joe E1einp /0 f�t< /tu Y(tft/e�(-f t p NAME /� < PRESENT ADDRESS TEL a CONTRACTOR: •'Cm !t 'c14 f .sy LC,KIM, ( /u car El fro/Gtl' NAME MAILING ADDRESS TEL c 2 7c --7 C &Residential 0 Commercial ( Est Cost of Construction$ W /�2.10 Home Improvement Contractor Lie.# !1.13053 Construction Supervisor Lic.# 95 3 1/ Workman's Compensation Insurance: (check one) f ❑ I am the homeowner 0 I//am the sole proprietor -U I have Worker's Compensation Insurancea/ Cl Insurance Company Name: /j�' Worker's Comp.Policy# DSC 5.,0 Q?Z tt.O 271• of WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #oMSquares 2 D ( )Repove existing*(inn.2 layers) Insulation Old Kings Highway/HistoricDist. ( )Replacing like for like Pool fencing *The debris will be disposed of at - VLt,/WI W h 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 for denial or,revocAatign of my ' se and for prosecution under M.G.L Ch.268,Section 1. r Applicant's Signature: (.7*' Date: 6 ) 17/ l a Owners Signature(or attachment) /J Date: Mar;Approved By: ` ee r Date: 8—/.5 mg designee) EMAIL SS: Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 R.of Wetlands: 0 Yes 0 No 0 Yes 0 No The Commonwealth of Massadhusetts t�— —'t Department of Industrial Accidents 5—•..1�t=; P 1 Congress Street, • _:` 11: .s" Boston,MA 02114- 0 2017 www.massgov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/plumbers. TO BE FILED WITHTIJE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/Individual): 176-7 jesa -171ry Address: 17c S y L o w v 8(cc .' P • City/State/Zip: Y6u'M ditirt Phone#: SOS — 7 de) 27e)'? Are you au employer?Check the appropriate box: Type of project(required)- I.d I am a employer with / employees(full and/or part-time).* 7. 0 New construction 20 1 am a sole proprietor or partnership and have no employees working for me in 8. 1;1 Remodeling • any capacity.[No workers'comp.insurance required.] 3. I am a homeowner doing all work 9. ❑Demolition ❑ gmyself[No workers'comp.insurance requited.]t 4.❑I an a homeowner and will be hiring contractors to conduct all work on my property. t wit 10❑Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietor with no employees. 12.❑Plumbing repairs or additions 5.0 I am a general contactor 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.* 6.0 We are a corporation and its officers have exercised their right of exemption per MQ,e. 14.❑Other 152,§1(4),and we have no employees.[No worker'comp.insurance required.] *Any applicant that checks bat#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. !Me sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that's providing workers'compensation insurance for my employees. Below is the policy and job site information. • Insurance Company Name: ( 4,04 Policy#or Self-ins.Lie.#: 6S"LS(j V 4 f)27 q1/V 37 2 i L/ Expiration Date: ?SI)! Job Site Address:7v 2i TS • 1 Ci e City/State/Zip: yet/Anton n# Attach a cropy of the workers'compensation policy declaration page(showing the policy nuer 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 hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signature: Date: rT t/,?I t phone#: 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#: A�a CERTIFICATE OF LIABILITY INSURANCE DATE IM"3D 6)la THS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLJCIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: M the certificate holder is an ADDITIONAL INSURED, the policy(ea)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 canter rights to the certificate holder In lieu of such eMorsemenl(s). PROWcee CONTACT JULI MCDOWELL Schlegel s Schlegel Ins Broker PHONE FAX (508) 711-0663 {A1c Nn Ire* (508) 771-8381 IAC Na: 34 Main Street AIML Neat Yarmouth, MA 02673 AmmEmp schlegelinsuranceegmail.com INSURERS)AFFORDING COVERAGE RACs INSURER A:MOUNT VERNON BSUR® INSURER B:CNA TIMOTHY KEATING DBA KEATING INSURE C: CONSTRUCTION INSURER 0: 54 LOWER BROOK RD INSURERS: SOUTH YARMOUTH, MA 02664 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD. INDCATED. NOTWITHSTANDNO ANY REOUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTFICATE MAY BE ISSUED OR MAY PERTAN, THE INSURANCE AFFORDED BY TI•E POLICIES DESCRIBED HEREN IS SUBJECT TO AU.THE TERMS, EXCLUSICNS AND CONOlTIONS OF SUCH POUCIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS ._._—AWL SUER --_-- POLICY Er-Pout,'DPu .._._ LTR TYPE OF INSURANCE INSR VIVO POLI CY NUMBER s*MWNYWD' ) IMMOYYYY) A GENERAL LIABILITY • GL 2548741 3/20/18 3/20/19 EACH OCCURRENCE $ 1.000,000 AMAGENTED X CCr•MERCIALGEPERALLIABILITY PRFMISF4°a occnncel $ 500.000 CLAMS•MADE ' X OCCUR ' MED DIP(Ary one()tram) $ 10.000 • PERSONAL ADV INJURY S 1.000,000 GENERAL AGGREGATE S 2.000,000 GENII.AGGREGATE LMITAPP�LIEIS PER PRODUCS�COMP/OP AGG $ 2,000.000 cR0 —1 POLICY ' I 1 LCC s AUTOMOBILE UABRRY CieIdEkjINGLL LIMIT $ PNYAUIO IIBEEODILY INJURY(Per person) S ALL ONTED SCHEDULED BODILY INJURY(Per accident) S AUTOS AUTOS NON-0VMEDo $ HIRED AUTOS AUTOS (Per accident) $ UMBRELLALIAB _OCCUR '• EACH OCCURRENCE S EXCiSSLOB CLANS-MADE AGGREGATE t OED RETENTIONS $ gANYDRO KEAERSPL COMPENWSABTKW IlTY 6S59UB0224N37214 39/18 3/9/19 AU- OTR - TRFR YIN ANY PROPRInTOR/PARTNEREXFLUTNE NIA EL.EACH ACOCEM $ 100,000 OFFICERMEMBEREXCLWED? (Mandatory In NHl E.L.DISEASE- AEMPLOYEE $ 100,000 aye I PTIONcFO ELDISEASE-POLICY LIMIT $ 500.000 DES�RIPTgN OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (AS ACORD101,Adsdonel Renatea Schedule,B moa spice YInd ned) TIMOTHY KEATING HAS ELECTED TO BE COVERED UNDER HIS CURRENT WORKERS COMPENSATION POLICY • CERTIFICATE HOLDER CANCELLATION • SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELLED BEFORE TIE EXPIRATION DATE THEREOF, NOTICE WILL BE DEUVERED N ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE • I ®1988.21I COR' ORPORATION. All rights reserved. ACORD 25(2010/05) The AC ORD name and logo are registered marks of A -D Phone: Fax: E-Mall: . • Keating Constructionnn 'o r? Home Improvement contractor registration: DATE July 9,2018 143053 Quotation 0 1 54 Lower Brook Rd So.Yarmouth MA 02664 Phone(508)760 2702 tlmkeatlna660hotmail.com Quotation valid until: October 9,2018 Proposal for: Job name/location: Joe Elelne Same 70 Rita Ave • Yarmouth Ma 717 880 2834 We hea • submit speciflcatons and Strip 3 layers of roof shingles off entire house and renail any loose decking Install 3 ft of Ice shield on all lower edges Install 30 lb tar paper Install new vent pipe flanges Install new white 8 Inch drip edge Install Certainteed Landmark 30 yr architectural shingles • Install ridge vent on entire peaks Install new lead chimney flashing All debris and trash will be removed and disposed of properly Only Items specified above are included in this proposal. Chimney flashing replacement is not Included In this proposal Rotted wood repair is not Included in this proposal. Materials guaranteed by manufacturers.Workmanship guaranteed by Keating Construction for 10 years. _ 1/3 payment due at start of job and remainder upon completion Acceptance of Proposal: 110/4,(21C • /w Date of acceptance: ` � Acceptance of Proposal: tfL r.15t A( f ' Date of acceptance: �7 The above prices, specifications and c•j ditions are satisfactory and are hereby accepted. / C EJ l C Convnonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Construct`o{tsJ ; Specialty CSSL-099351 • ':r 0,i:. �3�ires• 05/11/2020 TIM 13 KEATING '�•t „—`,' titi•,. 54 LOWER BRJON'R',.it , I % .r SOUTH YARM6L p Me°- 28 3 'Svc '``:,4 o CS'330� is • Commissioner l,^�— o_________, —•�..�—._.... rJye C&mmonweald of G�llir.Lami tie Office of Consumer Alai s 6 Business Resuiafion HOME IMPROVEMENT CONTRACTOR TYPE:Individual moitratagn gaisteign J143053 - 06/13/2020 TIMOTHY KEATING D/B/A KEATING CONST,. TIMOTHY B.)(EATING- "'sJ -Qs- 54 OYARMOUTH,MA 02664 Undersecretary