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Home My WebLink AboutBLD-19-002965 Office Use Only I dog" 4R s -': '7- . Permit# .n C �.� C �i'�sfS. ,,�- Amount "Permit expires 180 days from ` iss yv a.or rik e,04 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH RECEIVED Yarmouth Building Departmen. 1146 Route 28 NOV 14 2018 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 BUl , � PARTMENT BY . A- CONSTRUCTION ADDRESS: 70 Le.lrtwuJ? f l yerfru nnL 0K4 • ASSESSOR'S INFORMATION: • Map: Parcel: 1 OWNER: M;kt f 9ein r -3 0 J-Aue taw? f /molt, 00 NAME PRESENT ADDRES TEL. # . CONTRACTOR: ITA./ k-l44-r`Ztj SYLot,jrr&rau!' tutnmllt. tii4 NAME MAILING ADDRESS TEL#5O'S ')60 Z2tZ vo dResidential 0 Commercial Est Cost of Construction$ Cy/p SO Home Improvement Contractor Lic.# /y10 S1 Construction Supervisor Lic.# lc?1J Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor 04 have Worker's Compensation Insurance Insurance Company Name: C/44 Worker's Comp.Policy# 65 clued 37Z/y WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares / y ( Jiemove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing "The debris will be disposed of at 1/4/Mm,tt h. t 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 of my license and for prosecution under M.G.L Ch 268,Section 1. Applicant's Signature: 't Date: ////t///f Owners Signature(or attachment) 474-- / Date: Approved By: Date: 1/ Building Official(or d n EMAIL ADD S: M Zoning District: Historical 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 Massa husetts %) �_ Department ofIndustrial Accidents —_tragi= 1 Congress Street,Suite 100 •T =alit_ Boston, MA 02114-2017 '3cw, 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): - Address: Sr/ Lowe,- /2rcv - pill City/State/Zip: "/e.s,1�tz.. /w¢ D 2,0Y Phone #: Sod- 76'0 Z70Z Are you an employer?Cheek the appropriate bon: Type of project(required): I I am a employer with / employees(full and/or part-time).*. 7. ❑New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 3. I am a homeowner doingall work myself r 9. ❑ Demolition ❑ y [No workers'comp.insurance required.] 10 ❑ Building addition 4.❑I am 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 no employees. 12.❑Plumbing repairs or additions 5.❑I am a general contractor 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 MGL e. 14.❑Other 152,11(4),and we have no employees. [No workers'comp. insurance required.] *Arty 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-contractors have employees,they must provide their workers'comp.policy number. I ant an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: (it/i4 Policy#or Self-S.Lic.#: 45'_Cc u 40221./.v7 - 2 /rr Expiration Date: 3/5//s' Job Site Address: City/State/Zip: 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: Date: ///tfh Phone#: ,SO 741° 2>a? 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 contract 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 contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and,if necessary, supply sub-contractor(s)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 advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. 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 The Department has provided a space at the bottom 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 given 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 future 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 bum 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 I Congress Street, Suite 100 r ' Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or I-877-MASSAFE Fax# 617-727-7749 Revised 02-23-15 www.mass.gov/dia ACCPRO CERTIFICATE OF LIABILITY INSURANCE DATE(111.1/D3/6 18 THS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER TEE 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 policy(ies) 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). PRODUCER CNAME: A :ANMEJULI MCDOWELL Schlegel S Schlegel Ins Broker PHONE Flex (50e) 701-0663 AM Na Ern. (508) 771-8381 IAIC Nd: 34 Main Street LAM schlegelinsuranceegmail.com West Yarmouth, MA 02673 INSUFEASLAFFORDUNO COVERAGE NAION INSURER A:MOUNT VERNON ��® ..`__. INSURER B:CNA TIMOTHY ICEATING DEA KEATING INSURER C: CONSTRUCTION INSURER D; 54 LOWER BROOK RD INSURER E: SOUTH YARMOUTH, MA 02664 INSURER F: COVERAGES CERTIFICATE N UMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE USTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTW(THSTANDNG 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 TIE POLICIES DESCRIBED HEREN IS SUBJECT TO AU.THE TERMS, EXCLUSIONS AND CONDTICNS OF SUCH POUCIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR.._.__ . .. _._._ _..____ ADOL SUER ..—.._. __.._--__-� POL1CYErP—Royce EXP LTR TYPE OF INSURANCE INSR 1WD POU LY NUMBER LM MImNYYY) IfMIDdYYYY) LINTS A GENERALLIASIUIY GL 2548741 3/20/18 3/20/19 EACH OCCURRENCE • S 1.000.000 X COMMERCIALGEIE RAL LIABILITY DAMAGE RA MISES(Fa RENTED $ 500.000 CLAIMSMADE Lx.I OCCUR - - MEDE '(Ary one person) $ 10.000 PERSONAL&ADV INJURY S 1.000,000 GENERAL AGGREGATE S 2.000,000 GENLAGGREGATE LIMIT APP'LES PER PRODUCTS-COMP/OP AGG $ 2.000.000 —1 POLICY EC I LOC f AUTOMOBILE LIABRJTY COMBINED SINGLE L(Ea accident) RAM ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per adient) S AUTOHIRED AUTOS —AUTOS AUTOS ED PROPERTY DAMAGE f (Per accident) S UeeELLALIAB _OCCUR EACH OCCURRENCE f EXCESS UAB CLAIMS-MODE AGGREGATE S . DED RETENTION f $ B KOAPLOOWEL6ATION 6S59UB0224N37214 3/9/18 3/9/19 WCS TATU- TH- S GFR AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N NIA E.L.EACH ACO DEM $ 100,000 OFFICE FOMENTER EXCLWEDT (MaSalory In NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 Nye desaioe under DES�RIPTK)N CF OPERATIONS below E .DISEASE-POLICY LING $ 500.000 - DESCRIPTION OF OPERATORS I LOCATIONS I VEHICLES (Mach ACORD 101,Adafonal Renarb Schedule,N more smell Is repelled) 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. AUTHORIZED EPRESENTATNE - • ®1988 21 a COR a ORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of A -D Phone:. Fax: E-Mall: Keating Construction Home improvement contractor registration: DATE November 6,2018 143053 • Quotation# 1 54 Lower Brook Rd So.Yarmouth MA 02664 Phone(508)760 2702 timkeating66(ilhotmail.com Quotation valid until: December 20,2018 Proposal for. Job name!location: Mike Higgins Same 30 Lakewood Rd Yarmouth Ma We hearby submit specificatons and 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 Option to add back rubber roof $1,650.00 extra All debris and trash will be removed and disposed of properly Only items specified above are included in this proposal. Estimate does not include refacing 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: $4,950.00 Senior Citizens discount included 113 payment due at start of job and remainder upon completion Acceptance of Proposal: _. i� Date of acceptance: ft(l-.( f E -- Acceptance of Proposa" -4+ Date of acceptance: The above prices, specifications and conditions are satisfactory and are hereby accepted.