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Home My WebLink AboutBLD-19-001946 ottikees % N -seri 4' Amoont °cas r I Permit expires 180 days from 8 issue date EXPRESS BUILDING PERMIT APPLICATIO "RECEIVED ZECEIVED TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 OCT 0 2 2018 South Yarmouth, MA 02664 t? —,! •• • (4) (508) 398-2231 Ext. 1261 PART CONSTRUCTION ADDRESS: 22 FiOOt1V' Varnu1 kvi du )? ASSESSOR'S INFORMATION: Map: G3 Parcel: 3 8r OWNER: hn QOole 22 µriovv C1 yarmzu z, la 02-CV NAME PRESENT ADDRESS p TEL # CONTRACTOR: rcet re4"h\'1} S'1 `0We/ Ora.AJ yq(•r1W`Tt` Y�" .c'O&k lad Z 6z NAME MAILING ADDRESS t TEL# Residential ❑Commercial Est Cost of Construction S 6 14 u Home Improvement Contractor Lie.# /4/30.57 Construction Supervisor Lie.# 9S 317 Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor O I have Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy# WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # 'Roofing:41of Squares /5 ( )Remove existing' (max.2 layers) Insulation Old Kings Highway/Historic Dist ( )Replacing like for like Pool fencing 'The debris will be disposed of at Yarm UJB 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 rev vv cation of my license and for prosecution under N O L Ch.268,Section 1. Applicant's&lenature: per" M•'ot� Date: la?I/S" Owners Signature(or attachment) Date Approved By: ✓ itiY Date: 10 - a.- Building Official(or designee) EMAIL ADDRESS: Zoning District Historical District 0 Yes ❑ No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District Within 100 ft.of Wetlands: 0 Yes 0 Na 0 Yes 0 No The Commonwealth of Massachusetts � -ae54- =fir/ Department ofIndustrial Accidents J =rel= 1 Congress Street,Suite 100 • Boston, MA 02114-2017 • • . www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH TEE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual):en.? k m',5 Address: S y 4, e group f/ City/State/Zip: yG(n7ankt. v vI 0 2 6a'r Phone#: 506- 76/4 2)4re Are you an employer?Check the appropriate box: Type of project(required): L.8 I am a employer with I 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. NeRemodeling • any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself o workers'co 9. ❑Demolition II1 top. nsurance requred]t 4.❑I am a homeowner and willurbe hiring contactors to conduct all work on properly. I will 10 0 Building addition ensure that all contractors either have workers'compeasadou insurance or are sole 11.❑Electrical repairs or additions pmpriemrs with no employe--s. 12.❑Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet These sub-contactors have employees and have workers'comp.insurance.: 13.❑Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 157,§l(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box kI 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 coma-actors mast submit a new affidavit indicating such. *Contactors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employes. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am=employer that is providing workers'compensation insurance for my employees. Below is the policy and job site informadon. Insurance Company Name: C/144 Policy#or Self-ins.Lie.#: 655 90,10 22y v 3 D 2e> Expiration Date: 7/s// Job Site Address: Zt Hoyte Pt) City/State/Zip: t-✓ YG/&,cc$2 Jn/ 02(73 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$250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penahlos of perjury that the information provided above is true and correct Signature: VA. � -ea�� Date: /dal Phone#: Ste— 7 (u 77el Official use only. Do not write in this area,to be completed by city or town officiaL City or Town: Permit/License# Issuing Authority (circle one): 1.Board of Health 2. Building Department 3.City/Town CIerk 4. Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: • ems ® - --- — _ _.. ass. .-•-- •- - t+tKlltltrAlt Vt LIAbILII T 11YSUKANCt Q.TEIMM YYTY) 3/1.6/18 THIS CE TIFY:AT.E LLS ISSUED AS A uAT6 ERR OF LafO'PM"TION O_Y AtE3 CONFERS WO P.Y.19TS UPON THE CEP.7:."CA E)". ..^.E t TNT. CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL.INSURED,the policypes) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). . r"C1d"'F" NAME: JULI MCDOWELL Schlegel & Schlegel Ins Broker PHONEFAX (5081 711-0663 34 IAq:.Nil F.lj (508) 771-8381 w/C Na: ��"" =`a` *Daws. schlegelinsuranceygmail.com West Yarmouth, MA 02673 INSURERS)AFFORDING COVERAGE NAIC$ IINSURER A:MOUNT VERNON I® INSURER B:CNA TIMOTHY KEATING DSA KEATING lRLSURERCJ CONSTRUCTION INSURERD• 54LOWER BROOK RD ---------.._ .. .INSURER E: SOUTH YARMOUTH, MA 02664 MEM F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICES OF INSURANCE USTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDCATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WiTH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAN. THE INSURANCE AFFOPDED BYTFE POLICIES DESCRIBED HEREN IS SUBJECT TO ALL THE TERMS, EXCLUSOMS A_N!OCONIYTION-S OF SUCH POLICIES_L WTS SHOWN MAY HAVEEFS REDUCED BY PAID CLAW INSR ADOLSUBR -- iOUC/EFPOLICY E - ------- LTR TYPE OF INSURANCE IDOL MND POU CY MACER PAMIID/YYYY) (MM/DDIYYYYI UMTS . A au. •J-Ewa L . F XP GL 2548741 3/24/19 • 3/24/14`rJ.ci:Ct,CUmrrx: s a DO0.ODD DAMAGE TO CONMERCLALGEIERALUAB 1.17Y REaartnrn1 $ 500.000 (CtAMSMADE X OCCUR • ncu EN'-*Arty one P'R*a*j $ 10.000 PERSONAL a ADV INJURY $ 1.000.000 111 GENERAL AGGNtGAIE $ 2.0000,000 GENILAGGREGATE LMT APPLES PER I PRODUCTS•CONP/OPAGG $ 2,000.000 I POLICY! Fief ILOC s AUTOMOBILE UABIRY �OMeaded) NGI.ELMAm $ ANY MIST INJURY IPerpmalJ a ALL OSOWNED SCHEDULED ., {BODLecVINJURY(PaccNbnt) $ NON-OWNtU ENCTEttn DAMI4GE $ —JIIREDAUT9.S _AUTOS $ UMBRELLA LAB ?SLUR I EACH OCCURRENCE $ EXCESSLIAO CLAMS-MADE! AGGREGATE $ DED RETENTION$ ( I s B MARKEISCOMPENSATION I ` 6S59UB0224N37214 3/9/18 3/9/19 TORY I,WCSTAa.TT, Ochi- POO EMKOY[NYumUTY I t MIYPROPRIETORMARTNERE XLCISR.E Y'N N/A I£L EACH ACCIDENT Is 100.000 OFFICE MEMBER EXCLUDED? N the..=, ,,N,N; EI PIMFA<F-EA EMPLOYEE $ 100.000 Iyef,tleSa�De untler DESCRIPTIONOFOPEPA-IONS below EL DISEASE-POLICY LIMIT $ 500.000 I ! (ESCRIPTION OF OPERATIONS I LOCATORS I VEHICLES (AttacR AGGRO 1St A0Mtcnl ReRHM SCnS.W MINI spa Y rewind) • TrriOTHY BEATING HAS ELECTED TO BE COVERED UNDER EIS CURRENT WORKERS C.OIA2ENS3.TION POLICY • CERTIFICATE HOLDER CANCELLATION STriitito Air O'THE ASvvt DE SYNCED FOLIC ES SE CA.:ELLER arcc jll THE EXPIRATION GATE THEFeOF, NOTICE .WILL BE DELIVERED aI ACCORDANCE WITH THE POLICY PROVISIONS. {AUTHORIZED REPRESENTATIVE { / V 98662 0 CO Rb"CORPORATION. All rights reserved. ACORD 25(201 W0&) ,The ACCRD name and loco are roistered marks of A 0 D Phone: Fax: E-Mail; . Keating Construction Home improvement contractor registration: DATE September 18,2018 143053 Quotation# 1 54 Lower Brook Rd So.Yarmouth MA Phone(508)760 2702 timkeating660hotmail.com Quotation valid until: December 18,2018 Proposal for: Job name!location: John Poole Same 22 Hoover Rd West Yarmouth Ma 02673 ran O'r rnm NVV 'J/ JJYO We bssrhy a..hrnl4 aprIllw slang s..., 4 Descriptiony Strip roof shingles off entire house Install ice and water shield on all lower edges Install 30 lb tar paper on entire roof install drip edge Install new vent pipe flanges Install Certainteed Landmark 30 yr architectural shingles Install ridge vent on entire ridge • 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. Rnttarr vend ronair it not intit vier{in thio nrnnntal Materials guaranteed by manufacturers. Workmanship guaranteed by Keating Construction for 10 years. We propose hereby to furnish materials and labor for the sum of: $6,000.00 Balance due upon completion ((�� Acceptance of Proposal: �. Po0/// Date of acceptance: t7( 2 t) I" t Acceptance of Proposal: �r..A. ,6 t< — Date of acceptance: 11251 r A- The above prices, specifications and conditions are satisfactory and are hereby accepted. a • wnmronwee un of meeeeuaea i®) Division of Professional Licensure MEI woes.'apun g99Z0 vyy'Kin 0IAnjdA'09 Board of Building Regulations and Standards •,' 'GU>1001:18H3Mbl tr9 • ConstructioiS'd Meyr Specialty DRILY-3)1'BAH10WI1 4 •CSSL-099351 . Eyires: 05111/2020 tiSNO0 ONIlv3)1 v/910 �- . ONI1v3N AHlOWIl ' OZ07/EU90 E90E41 TIM B KEATING R .z-) t• - I(1 uo ei dui.. ' Ucp Wal! 64 LOWER BR�OTIROAD B I SOUTH VARMOkfTF�'f1�A 6 !. -: IenPN!WI 3dAl 9OlOValNO31N3W3AO9dW13WOR -- f�lSti Jd��t� uogeinBetl ssautsne g s IellvrawrKuop yo eo0+0 -----/1^o• --' Commissioner CZ- r 6 •