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Home My WebLink AboutBLD-19-003633 2 Office Use Only ii r • t-t p:. Permitilp .'iimr..,� y' Amount 5 D� I ,4 •,%],.< ,e aid$ 1 Permit expires 180 days from 9 issue date • 80D-ri-0031:733 EXPRESS BUILDING PERMIT APPLICATI St E C E I !� E D TOWN OF YARMOUTH Yarmouth Building Department DEC 17 2018 i 1146 Route 28 South Yarmouth, MA 02664 riuit c,��µ��irii .,,, ur- _S �Ci1T=1lC�S.1 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: I u S Grec+ (kV S1-Vel it-i Y4rMQJfi /1-44 0266Y ASSESSOR'S INFORMATION: • Map: / Parcel: OWNER: re,k k $iTho Acts (ct s- G-te- - cup *to QT Yet/iv , rte- NAME //�� PRESENT ADDRESS v TEL # L.# 1CONTRACTOR NAME kms,-r7'1y St� e9wc.G ADDRESS F 1 4(fr1O li,✓b4 026 5 W Residential 0 Commercial Est Cost of Construction$ /✓ . Home Improvement Contractor Lie.# ) C( 7 0 5 3 Construction Supervisor Lic.# 99 7i / Workman's Compensation Insurance: (check one) (have • 0 I am the homeowner 0 I am the sole proprietor 0 Worker's Compensation Insurance Insurance Company Name: C. ,v' elWorker's Comp.Policy# 65540 0 (5 22 gt 4)372/y WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares 30 ( )Rorie re existing* (max.2 layers) Insulation Old Kings Highway/Historii/cDist. ( )Replacing like for like Pool fencing . / *The debris will be disposed of at: et f Al chi jte, 111 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.O.L.Ch.268,Section L Applicant's Signature: � . -� Date: 12)/P 1/V Owners Signature(or attachment) Date: n /� Approved By: dDate: l� —/7—/2T . Buil • ' ord ignee) ADDRESS: Zoning District: Historical District 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No ' Water Resource Protection District Within 100 R of Wetlands:' • 0 Yes 0 No 0 Yes 0 No The Commonwealth of Massachusetts ' Department ofIndustrial Accidents ='=lir I Congress Street,Suite 100- r Boston,MA 02114-2017 vc* www.wass.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): 1 /+•-1 k—ec,fitn f Address: SW fic'wL 9 J City/State/Zip: Yetw)a <'t 4- 02667 Phone#: Sob- '250 2?a t Are you an employer?Check the appropriate box: Type of project(required): 1E11 am a employer with I employees(full and/or part-time).* 7. 0 New construction 2.0 1 am a sole proprietor or partnership and have no employees working for me in 8. E7 Remodeling any capacity.[No workers'comp.insurance required.] 10 I am a hot eownefdoing all work myself[No workers'.comp.insurance requited.1 r 9. ❑Demolition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 0 Building addition 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 5.0 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 am a corporation end its officers have exercised their right of exemption par 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 tContractrs that check this box must attached art additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the subcontractors 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 ardJob site information. Insurance Company Name: C NAV • Policy#or Self-ins.Lie.#: CS ,;4 o D o 2 7 Lt n,? t' 71 t, Expiration Date: .3 A,/$ Job Site Address: /(if &ter#- kfefiG. I'L City/State/Zip: 0 L4> 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 certifir under the pains and penalties of perjury that the information provided above is true and correct. Signature: pate: It r/ Z // Phone#: SOY 7 60 a)c/2-- Official use only. Do not write tn,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#: Keating Construction Home improvement contractor registration: DATE December 5,2018 143053 Quotation# 1 54 Lower Brook Rd So.Yarmouth MA Phone(508)760 2702 timkeating66@hotmail.com Proposal for: Job name/location: Ralph Simonds Same 145 Great Western Rd Yarmouth Ma 02664 717 3816746 We hearby submit specificatons and � • i-i..!'i h, ad ,. euamY�MYf� , 2.'?Su ..l Strip roof shingles off entire house and renail any loose decking Install ice and water shield on all lower edges and valleys Install 30 Ib tar paper on entire roof and new drip edge Install new vent pipe flanges Install Certainteed Landmark 30 yr architectural shingles Install ridge vent on entire ridge All debris and trash will be removed and disposed of properly a 9 Only items specified above are included in this proposal. Chimney flashing replacement is not 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: $9,500.00 Senior Citezens discount included Balance due upon completion 1/3 Acceptance of Proposal: t l6 '� Date of acceptance: /L/7 / / Acceptance of Proposal: _411. Date of acceptance: i 74 The above prices, specifications and conditions are satisfactory and are hereby accepted. °"�'"�'°°" Ac R CERTIFICATE OP LIABILITY INSURANCE 3/16/18 THS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY MD CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS 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,MD 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 terns 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). PROWLER ,N to JULI McDOWELL Schlegel S Schlegel Ins Broker PHONE FAX (506) 771-0663 (ART Nn FAH (508) 771-8381 evc Nd: 34 Main Street E-MML West Yarmouth, MA 02673 ADDRESS: schleaelinsurancVERAGE Loom INSURERS)AFFORDING COVERAGE RAC. INSURBtA:MOUNT VERNON INSURED INSURER B:CNA ' TIMOTHY KEATING DBA KEATING INSURER CONSTRUCTION INSURER D: 54 LOWER BROOK RD INSURER!: 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 INDICATE). 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 THE POLICIES DESCRIBED HEREN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONATIONS OF SUCH POUCES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR..—..----'_______ ___AWL SUBS ---- POLICY EFF POLI CY MP LTR TYPE OF INSURANCE INSR WVD POUCY MIMBER RA MIW!YYY) (MMNO'YYYY) UMTS A GENERAL US ,/ GL 2548741 3/20/18 3/20/19_EACH OCCURRENCE s 1.000.000 X CCMNERCIALGENERAL LIABUTY PDR MISTS Ea°mneimen) s 500.000 CUIMSNIADE I X OCCUR ' MED EXP(Ary onepssm) $ 10.000 PERSONAL&ADV INJURY S 1.000.000 GENERAL AGGREGATE $ 2.000.000 GEN'LAGGREGATE LMIT APPPLEIS PER PRODUCTS•COMP/OP AGG $ 2.000.000 7 POLICY�FRJOT 1 1 LOC $ AUTOMOBILE LIABILITY (Ea SINGLE LIMIT (Ea moderl) S ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS NON OWNED PROPERTY DAMAGE s HIRED AUTOS —AUTOS (Per accden() _ S UMBRELLA LIAB OCCUR EACH OCCURRENCE _ s EXCESS LIAR CLAIMS-WOEAGGREGATE f — DED RETENTION I $ B VARRERSCOMPENSATx1N 6S59UB0224N37214 3/9/18 3/9/19 weSIATU- DTH- ANOEMPLOYERS'LIABILrrY TfIRYlimaR FR ANY OFFIIIR�M N REXCLI.O o N NIA EL.EACH ACOCENT $ 100,000 (tlMyaeSabry In NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 DESRlegl Nue PERATIONS below E.L.DISEASE-POLICY LAM S 500,000 LESCRIPTION OF OPERATIONS I LOCATIONS I VEIICLES (Math ACORD 101,Adilional Re mirk*ScJMd ie,I(more space le mad rid) 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. AUT14OR210 REPRESENTATIVE • 01988-20 r CO- M ORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of A • - Phone: Fax: E-Mail: