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Home My WebLink AboutBLD-19-3194 d O i.ce Use Only .O Y 9ie a sr .40 -1900 31 . C Ammmt -._%. '��,-di.....itt3Permit expires 180 days from _.�. issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH RECEIVED Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 NOV 2 6 2018 i (508)398-2231 Ext. 1261 . BUILDING DEPARTMENT CONSTRUCTION ADDRESS: GY/ /" r$tt!nfs f! `e1 Vein 011/47 ivy ASSESSOR'S INFORMATION: Map: • / d Parcel: Q 3 OWNER: G"bdel CO(lit gve7 80 44:0#,A We Gn yet-in-et- NAME PRESENT ADDRESS TEL. if CONTRACTOR: 1 •M h 01:0/ 37 `owe alar- /' V'vtn&4 co k- Ira 2 20? NAME MAILING ADDRESS TEL.# • Yy e• o ❑Residential 0 Commercial Est Cost of Construction$ T S?`°d Home Improvement Contractor Lic.# !9'305) Construction Supervisor Lie.# (53r) Workman's Compensation Insurance: (check one) ' 0 I am the homeowner 0 I am thettsole proprietor �Yhave Worker's Compensation Insurance . Insurance Company Name: L MA ' Worker's Comp.Policy# 65$4'0 Dee tune 21.7 WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # de rani Roofing: #of Squares 20 ( ) emove existing*(m .2 vers) Insulation • Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing 'The debris will be disposed of at .114' 'tr_ 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 ocati/onto off my license and for prosecution under M.G.L.Ch.268,Section 1. / Applicant's Signature: �' f(J--� Date: 1//ep //? Owners Signature(or attachment) ,� Date: ' Approved By: .7,....../2# Date: /77 Bui •' g ial(o designee) E ADDRESS: 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 Massachusetts '✓ —`.=, 1= Department of Industrial Accidents iel= 1 Congress Street,Suite 100 % -?41__ Boston, MA 02114-2017 • C.�. 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): kPtif+i•J eremn/'u*'fs'a, Address: SN G o Mrd'j.. 1/ City/State/Zip: ycn✓/.0.4 pa 62167 Phone#: 4 760 27dt Are you an employer?Check the appropriate box: Type of project(required): 1.8 I am a employer with l employees(full and/or part-time).* 7. 0 New construction 2.01 am a sole proprietor or partnership and have no employees working for me in 8. Q'Remodeling any capacity.[No workers'comp.insurance required.] 3. I am a homeowner doingall workmyself t 9. ❑ Demolition ❑ [No workers'comp.insurance required.] 4.0 I em a homeowner and will be hiring 10 ❑ Building addition contractors to conduct all work on myproperty. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no 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. These sub-contractors 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 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. tContrutors 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. 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: CA/A Policy/4 or Self-ins.Lic.#: 1sie✓c D?ew.v-nt/7 - Expiration Date: 3 I st/6 Job Site Address: 80 n/Siik^I°tte i'vl City/State/Zip: y mic deecr? 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 cera)'under the pains and penalties of perjury that the information providedaboveis true and correct Signature: Date: /l /re Phone#: Sd ') dei 7,tot. 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. Purruant 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 a joint 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 requirements of this chapter have been presented to the contacting 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 advisedthat 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 legibly. 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 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-7274900 ext. 7406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 02-23-15 www.mass.gov/dia ke044-zr/1f (G+ 1n2. Keating Construction a • • , Home improvement contractor registration: DATE November 12,2018 143053 Quotation# 1 54 Lower Brook Rd So. Yarmouth MA 02664 Phone(508)760 2702 timkenting9Af9+hntmail.cam Proposal for. Job name/location: Gulda Rodriguez Same 80 Nightingale Ln Yarmouth Ma 02664 508 7601317 We hearby submit specificatons and ttoh Install Certainteed Landmark 30 yr architectural shingles over 1 layer of existing roofing Install new vent pipe flanges Install white drip edge over all rakes Install ridge vent at all peaks Install new lead chlmneyflashing All debris and trash will be removed and disposed of properly Only items specified above are 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. . 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: .—• Date of acceptance: /1 //21/Sr Acceptance of Proposal :`7� w q Date of acceptance: v r2 [ The above prices, specifications and conditions are satisfactory and are hereby accepted. • A O CERTIFICATE OF LIABILITY INSURANCE DATE (RW3i ) 16/IB THS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THS CERTTYCATE 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(ies) 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 endorsements). PRODUCER CNAANACT ME: ,7ULI MCDOWELL Schlegel S Schlegel Ins Broker PHONE FAX (508) 711-0663 aNa Asti- (508) 771-8381 DUG Nd: 34 Main Street EM MAIL West Yarmouth, MA 02673 ADDRESS) schlecrelinsuranceegmail,com INSURER'S)AFFORDING COVERAGE NAILS INSURER A:MOUNT VERNON R6t1Rf0 - INSURER e:CNA TIMOTHY KEATING DBA KEATING INSURER C: CONSTRUCTION INSURER D 54 LOWER BROOK RD INSURER E: SOUTH YARMOUTH, MA 02664 INSURERF: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED 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 TIE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDTIONS OF SUCH POUCIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS INSR . ._..__.___.__ AODL SUBR._._._.._.._.....___ GOUCVEPI- POLICY EIIP •__.:.._ LTR TYPEOFINSURJWCE INSR WVD POU CY MISBER MMNONYYY) (AMIDO'YYYY) LIERTS A GENERALLIA&tlrY GL 2548741 3/20/18 3/20/19 EACH OCCURRENCE $ 1,000,000 DAMAGERTD O COMMERCIAL GENERALLAB61TV RIS(Ea occurrence $ 500.000 CLAIMSMADE X OCCUR MED EXP(Ary one person) $ 10.000 PERSONAL&ADV INJURY S 1.000.000 GENERAL AGGREGATE $ 2.00,000 GEMLAGGREGAATTIELMTAPPLEES PER PRODuaS-cowe/OPAGG S 2.000.000 ( 1 POLICY I 1 .Rpf r (I LOCc S AUTOMOBILE LIABRJTY (Eo aacccmrtSNGLE LMT $ ANYAUlO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per=Went) S AUTOS AUTOS NON--OWNED PROPERTY DAMAGE S HIRED AUTOS -AUTOS IPeraaiaeml S UMBRELLA LIMB _OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE AGGREGATE S DED RETENTION$ S B WORKERS COMPENSATION 6S59UB0224N37214 3/9/18 3/9/19 VVCTH- 7 RYTAITQ ATU- OFR MID EMPLOYERS'LIABILITY ANY PROPRIEIORRARTNERIEXEWThE YIN N/A EL.EACHACOEEM p 100,000 OFFICERMEMLER EXCEEDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEES 100,000 lint= eaesa�pq un er E.L.DISEASE•POLICYLMD'rS 500,000 DESCRIPTION OPERATIONSbefow IESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (beach ACOi0101,M lona Remade Schedule,amore spew 6 regal we 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. B! DELIVERED N ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE/A . • I �T 0 19882 0 COR ORPORATION. All rights reserved? ACORD 25(2010105) The AC ORD name and logo are registered marks of A 0 2D We*: E44*