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Home My WebLink AboutBLD-19-002485 �, Y t OO�jffi/ceeUUse Only //�, p O �0.. �Pfm,_itlf:/9'(/ av0 r 'Q .1:7�1 Amount S0 •� • -� < Permit expires 180 days from . • ". .... ;issue date EXPRESS BUILDING PERMIT APPLICATION R TOWN OF YARMOUTHC EYarmouth Building Department1146 Route 28 t—o--- ___Lif T 25 10; 007 South Yarmouth,MA 02664 gull-DN-67Z17-- - utLDt ��` 'o ^ (508)398-2231 Ext. 1261 ar ��°eP��Rt�`E =r CONSTRUCTION ADDRESS: co /I/ Cit../1 'c 7 L✓) yO(Mvtr4 6 if>, EJ ASSESSOR'S INFORMATION: In Map: Parcel: /� OWNER: mofr On Loc rho re '-l0 iVP 4)c4 I '-h (,L,/M/0011 NAME PRESENT ADDRESS TEL. It CONTRACTOR:---I l rettiny Ste toai $rOJAo 1? tei(MA) Col- 2(0 Z7d� NAnMMEE MAILING ADDRESS TEL.I 0 ljesidential I)Commercial 5 Est.Cost of Construction$ 5,500 Home Improvement Contractor Lic.# t9 3 OJConstruction Supervisor Lte.# %in Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 1 am the sole proprietor 0 1 have Worker's Compensation Insurance Insurance Company Name: GN4 - Worker's Comp.Policy# 6.SSjJ g 02z wv 772/Y WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # #ofS nares Z 0Frprf Off/ 04 I'j// Roofing: q O ( )Remove existing'(max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at Y4/4 COL 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 revocation f my license and for prosecution under M.G.I..Ch.268,Section I. Applicant's Signature: .. i -f Date Io ' Z5 i I S Owner Signature(or attachment) Date: Approved By: 111°&7) Date: /a /!�iE -Buil w leoL ADDRESS: Zoning District: - ,I�"4 44 , Historical District: .❑ Yes 0 No Flood Plain Zone: ❑ Yes 0 No i - - Water Resource Protection District: Within 100 R,of Wetlands: y',i i ❑ Yes. 0 No ❑ Yes 0; No {s�+'- 1l•: ,, It 7\4, . J • , t -,01.i.4Ass 44 • Keating Construction Home improvement contractor registration: DATE October 15, 2018 143053 Quotation# 1 54 Lower Brook Rd So.Yarmouth MA 02664 Phone(508)760 2702 timkeating66@hotmail.com Quotation valid until: December 15,2018 Proposal for•. Job name/location: Marion Lockhard Same 40 Nautical Ln Yarmouth Ma 02664 508 760 2839 We hearby submit specificatons and Description Install Certainteed Landmark 30 yr architectural shingles over 1 layer of existing roofing Install new vent pipe flanges All debris and trash will be removed and disposed of properly Only items specified above are included in this proposal. Estimate does not include relacing chimney flashing Rotted wood repair is not included in this proposal. Materials guaranteed by manufacturers. Workmanship guaranteed by Keating Construction for 10 years. We propose hereby to furnish materials and labor for the sum of: $5,500.00 Senior Citizens discount included 1/3 payment due at start of job and remainder upon completion / Acceptance of Proposal: fl/� Date of acceptance: /4 3 ` be Acceptance of Proposal:, fl*tLL Date of acceptance: /6 /23//S The above prices, specifications and conditions are satisfactory and are hereby accepted. _ �``v CERTIFICATE OF LIABILITY INSURANCE DATE (M"3i 6�8 THS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER HIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POUCIES BELOW. THS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,MD THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDMONAL INSURED, the policy(es) 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 ht lieu of each erdorsaneet(s). • PRODUCER NAME: JULI MCDOWELL Schlegel S Schlegel Ina Broker PHONE Fax (508) 772-0663 (Arc Nn Far (506T 7T2-6361 AC Not 34 Main Street ADDRESS: schlegelinsurance(gmail.com West Yarmouth, MA. 02673 INSURERS)AFFORDING COVERAGE NAICe INSURER A:MOUNT VERNON INSURED INSURER B:CNA • TIMOTHY KEATING DBA KEATING INSURER C: CONSTRUCTION INSURER D: 54 LOWER BROOK RD INSURER Ei SOUTH YARMOUTH, MA 02664 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE USTED BELOW HAVE BEEN ISSUED TO THE INSURED NAME)ABOVE FOR THE POLICY PERIOD INDCATED. NOTWITHSTANDNG ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY T)E PCLICIES DESCRIBED HEREN IS SUBJECT TO ALL THE TERMS, EMI USICNS AND CONDITIONS_OF SUCH POUCIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. !MSC— L R`—_- TYPE OF INSURANCE --- Amt.NSR SUER .__.__,__.__ POUCNEFF P4)DDYYP1 NSR.WVD POLICY HIItBER etaRD/YYY'() (tNAdYYYY1 LINTS A GENEeALLIABNTY GL 2548741 3/20/18 3/20/19 EACH OCCURRENCE S 1,000.000 DAMENTED AGE CCMMERCALGEIERALUABLTY RFMFSrcel S 500.000 CLAIMSMADE X OCCUR • MED DP(Any oneperem) S 10.000 PERSONAL 6 ADV INJURY S 1,000..000 ' GENERAL AGGREGATE S 2,000.000 GEN'[AGGREGATE 1ReTAPPLEr-iS PER PRiO ODUCTS-COSPP AGC S 2.000.000 —I POLICY f FR7 LOC ; C AUTOMOBILE MERRY (E�accMeOrt)ANGLE LIMIT S ANY AUTO BODILY INJURY(Per pram) S KL OWNED SCHEDULED BODILY INJURY(Per actIdem) I AUTOS NUTOS ON-OWNED PROPE Rn'DAMAGE S • HIRED AUTOS —AUTOS (Perecc.den0 S UtmRELLA LIAR _OCCUR EACH OCCURRENCE S ERCESS LIAR CLANS-MACE AGGREGATE S DED RETENTION; S FR B -WORKERS COMPENSATION 6S59UB0224N37214 3/9/18 3/9/19 T'Rv7AMRs UNN- AND EMPLOYERS'LABILITY AMY YIN M' NIA E.L.EACH ACO LENT $ 100.000 OFFICERMEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE 100.000 OrCRIPTION gsrri eurider DESOF OPERATIONS hebw E .DISEASE-POLICY LMR $ 500.000 (tBCRIPTIONOFOPERATIONS(LOCATIONS I VEHICLES Mach ACORD let Additional RanedU Schedule,If more apace I.regared) 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 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED N ACCORDANCE WITH THE POLICY PROVISIONS. AUTHOR2ED REPRESENTATIVE 1)1988-21 1 COR' ORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are reylstered marks of A -D \Phone:• Fax: E-Mail: The Commonwealth of Massachusetts ver —_Ct Department oflndustrialAccidents EEilt_ Fs I Congress Street,Suite 100• e: _t S�•'E-Lea- r~" Boston, MA 02119-2017 x`,0,5 www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. llaplitant information Please Print Legibly Name (Business/Organization/individual): - l -ri S ? �. ke471:15 Address: 1OwQ c (Sf,u P}. City/State/Zip: y4(indoft d2at, Phone If: Sok -6d 2-7de..-- Are you an employer?Check the appropriate box: Type of project(required): 1I am a employer with I employees(cull and/or part-time).* 7. EI New construction2.. 1 am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself[No workers'comp.insurance requited.]t - 9. ❑Demolition 10 ❑ Building addition 4.❑I em 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 employees. 12.0 Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.0 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 MGL c. 14.Q Other 152,§1(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. =Contractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have employees. If the sub-contactors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy andJob site information Insurance Company Name: (,v. Policy#or Self-ins.Lie.#: ‘c S 5� G)O 2'e 'l N 77 t'7 Expiration Date: I l S Il5 Job Site Address: 10 //pial-w r, I L, City/State/Zip: VA/wt r r•' 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 penalties of perjury that the information provided above is true and correct Signature: late: /OIZS //f.--..- Phone#: Se. Did 2702 • 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.CJt}r/Tpwn CJnrk 4.FJnit nJ inspector 9s/12/122M/20114111.7: 6.Other Contact Person: Phone#1