The URL can be used to link to this page

Home My WebLink AboutBLD-19-002697 n1;7'ine R. -, e40 fP-(#p/ /9-c F9y rye O :W I `3 - f4Amount � ,! Permit expires 180.dans from - (issue date • • EXPRESS BUILDING PERMIT APPLICATION • TOWN OF YARMOUTH RECEIVED Yarmouth Building Department 1146 Route 28 NOV 05 2018 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 aY. B ! = r9 sr: -TMENT / CONSTRUCTION ADDRESS: Lu (J-oi f eri C ed e '/crnw o,k fro a 1665, ASSESSOR'S INFORMATION: Map: // Parcel: owia 1e4n I'4FQ01; Li Golfer/ Owe yein.aik & o26<, NAME PRESENT ADDRESS TEL. # CONTRACTOR: - l i4A ��e< 144 SK Lpwe 6rdaL 7? Sri; 15°) ?.bZ • NAME MAILING ADDRESS TEL# ❑Residential ❑Commercial Est.Cost of Construction$ S5-5.00 Home Improvement Contractor Lie.# 1(4205) Construction Supervisor Lie.#1<357 Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor It have Worker's Compensation Insurance Insurance Company Name: CA/VC Worker's Comp.Policy# 6Sf4V0 Or?kl,Uj)zi y . WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing #of Squares 2 L ( )4kmove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing 'The debris will be disposed of at •/!✓wr cJi- M.Y Location of Facility I declare under penalties of perjury that the statements herein contained are true and coned to the best of my knowledge and belief I understand that any false answers) will be just cause for denial or revocatio of my license and for prosecution under MGL Ch.268,Section I. !/ APPlicant's Sigranue: Date: i4 J // Op Owners Signature(or attachment /> Date: - �` Date: /A-4,1-7—Vg Approved By: 4-�� F ^•:.tial . designee) ..4„cfi ADDRESS: • Zoning District Idistorical District 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No The Commonwealth of Massachusetts acr_= Department of Industrial Accidents c =WARE 1 Congress Street,Suite 100 r= �y Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business[organization/individual): y it'c7C.y Address: S/ L adite Ghat. • City/State/Zip: hut 0260 Phone #: 5 d 4- -)6.-a 2 7ez Are you an employer?Check the appropriate box: Type of project(required): 1.1t1 am a employer with ✓' employees(full and/or part-time).* 7. 0 New construction 2.❑1 am a sole proprietor or partnership and have no employees working for me in 8. LYJ Remodeling • any capacity.[No workers'comp.insurance required] 3.0 I am a hameovmerdoing all work myself[No workers'comp.insurance required.]t 9. ❑Demolition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 ❑Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employee= 12.❑Plumbing repairs or additions 5.01 am a general contractor and I have hued the sub-contractors listed on the attached sheet These sub-contractors have employees and have workers'camp.insurance.: 11 Rnof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152 §1(4),and we have no employees.[No winters'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 cantracton must submit a new affidavit indicating suck :Contractors that check this box must attached an additional sheet showing the came 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 providing workers'compensation insurance for my employees Below is the policy and job site information Insurance Company Name: Cu'A Policy#or Self-ins.Lic.#: IV fa ii OZ 2 4ni 3 7 Z/`y Expiration Date: /S//5 Job Site Address: 46 60Ifeef Cart- City/State/Zip: Y,M,41t , o7�t, 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 Oder the pales andln,s of perjury that the informwion provided above is true and correct Siznature: (L�� o�`pen° Date: ii/s//di Phone#: cd . 76e .? I L 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#: • • ;, • Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as"...every person in the service of another under any contact of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,..association,corporation or other legal entity,or any two or more of the foregoing engaged in ajoint enterprise, and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6) also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152;§25C(7)states "Neither the commonwealth nor any of its political subdivisions shall enter into any contact for the performance of public work until acceptable evidence of compliance with the insurance requirement of this chapter have been presented to the contacting authority." Applicant Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary, supply sub-contactors)name(s), address(es) and phone number(s) along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advisedthat this affidavit may be submitted to the Department of Industrial Accident for confirmation of insurance coverage. Also be sure to sign and date the affidavit The affidavit should be retuned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accident. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the boom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant Please be sure to fill in the permit/License number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any gives year,need only submit one affidavit indicating current policy information(if necessary) and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for fixture permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address,telephone and fax number. The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 r- • Boston, MA 02114-2017 Tel. # 617-7274900 ext. 7406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 02-23-15 www.rnass.0aov/dia K'eCay5 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 timkeatina66(a)hotmail.com Quotation valid until: December 15,2018 Proposal for. Job fame/location: Jean Rapplef A P P ° Same 46 Golfers CircleP[ Yarmouth Ma 02664 '` AflLA N o / n° IAA 878 558 8054 Q-(so K6e tower C/ We i_..aJ...submit specIficatona and ,�sat -- o Ona ...te=a>..,,....<•.:.. _ x.,_ «�`-, >...-s.,.- .'.,u,.. , av-,..,... <a .^ ><,_�r. ..:..�•;:,«^..k a. .i._.s TGFs-*...,�..... c.y.-.: K- .. _ ,a Strip roof shingles off entire house Install water and ice shield on eves and 30 lb tar paper on decking - Install new vent pipe flanges Install new white 8 inch drip edge Install Certainteed Landmark 30 yr architectural shingles Install ridge vent at all peaks Install new Azek trim boards on front middle left rakes east. ekcauC C Lan or ) p SI. DCS debris __J,_ _i end di wl uvui w and trash"will be reiTIO'veu and uwpuac'u of pi uperiy x yrk.� « a A5 £s-t_ i4M 4' 4 h5} Th it- '17'77,47-7x n� T '1',* ter+-'•-- Only items specified above are included in this proposal. Estimate does not include relating chimney flashing Rotted wood repair is not included in this proposal. Materials guaranteed by manufacturers. Workmanship guaranteed by Keating Construction for 10 years. IN0 propose hereby to furnish materials and labor for the sum of: $8,500.00 i 'sa ;walk WWcrCa. s di;cacr: u 113 payment due at start of job and remainder upon completion Acceptance of Proposal: eL- • Date of acceptance: 10 Acceptance of Proposal: Date of acceptance: ,ic 7,Z2.—/a r The above prices, specifications and conditions are satisfactory and are hereby accepted. 70 4- lot-clk • e i ° � ,Lt ` 2' 02 ? 3S! °° A. . . •_ (Vile Vommon Inca lr4 ly0&um-Aerie/A Office of Consumer Atfai &Business Regulation HOME IMPROVEfAENT CONTRACTOR TYPE:Individual again.aka Wit-tt1211 143053 06/13/2020 JTIMOTHY KEATING D/B/A KEATING CONST. TIMOTHY B.KEATING 54LOOWYAER BROOK MA 02664 Undersecretary • CommonwealthMassachusetts ®r Division of ProfessionalofMaa Licensurehusett Board of Building Regulations and Standards Constructioo-SLpervisor Specialty CSS L-099351 -_ E,t,pires: 05/11/2020 Ler" � r TIM B KEATING 1 _ 54 LOWER BROOK ROAD , , SOUTH YARMOUTH MA 0266 I. Commissioner C2 ACORO CERTIFICATE OF LIABILITY INSURANCE °"'E`""°°Y""' 3/16/18 THS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIRCATE HOLDER THS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THS 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('es) rust 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 .JULI MCDOWELL Schlegel & Schlegel Ins Broker PHONE FAX (508) 771-0663 (Arc Na Fal• (508) 771-8381 w/c Nd: 34 Main Street E-MAIL West Yarmouth, MA 02673 AmmEss, schlectelinsuranc COVERAGE 1.coon INSURE RIS)AFFORDING CVERAGE NAIL• INSURER A:MOUNT VERNON INSURED INSURER B:CNA TIMOTHY KEATING DBA KEATING INSURER C: CONSTRUCTION • INSURER D: 54 LOWER BROOK RD INSURER E: SOUTH YARMOUTH, MA 02664 INSURER 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 INDICATED. NOTWRHSTANDNG ANY REQUIREMENT,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 TEE POLICIES DESCRIBED HEREN IS SUBJECT TO ALL THE TERMS, E CLUSICNS AND CONATIONS OF SUCH POLICES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS INSR - ADDLSUER ---- POLICY EFF POLICY E%P._____ _ LTR TYPE OF INSURANCE INSR WD POLICYMILS3ER IMMADNYYYI IMMIOOIYYYY) L11115 A GENmuLIABILITY GL 2548741 3/20/18 3/20/19 EACH OCCURRENCE s 1,000.000 ED X COMMERCIAL GENERAL LAB LITY DAMAGE areRENns:mmck $ 500.000 CIAe.SMADE X OCCUR ' L£DEXP(Ary one person) $ 10.000 PERSONAL ILADV INJURY S 1.000.000 GENERAL AGGREGATE S 2.000.000 G�f EII N'LAGGREGATE LMITAPPLES PER PRODUCTS•COMPX)P AGG $ 2.000,000 POLICY I A Pig I 1 LOC cc S AUTOMOBILE DARER! (Ea ImrtjINGLLLMR $ ANYAUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTYDMMOE S HIRED AUTOS —AUTOS Per accident) _ S U&eRELLA LIAR OCCUR EACH OCCURRENCE _ S EXCESS DAB CLANS-MADE AGGREGATE _S DED RETENTION$ $ B RKERSCOMPENEATXJN 6S59UB0224N37214 3/9/18 3/9/19 . TORSTA� IFR AND F]1PLOYER3'IJA&LITY ANYPROPRIElOIVPARTNERIEXECUTNE Y/N NIA - EL.EACH ACO TEM $ 100,000 OFFICERMEMBER EXCLUDED? (Mande logy In NH) EL,DISEASE-EA EMPLOYEE $ 100,000 rvet d�atbe under DESCRIPTION CF OPERATIONS below E .DISEASE-POLICY LMR $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (Wash ACORD 1Ol,Adddonat Reeerb Sched le,8mon spc.Ism/tired) 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. AUTHORIZES REPRESENTATIVE • ®1988 21 1 •CORORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of A • - Phone: Fax E-Mall: