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Home My WebLink AboutlBld-20-001196 y Office Use Only o1'' . 4' s„; Q Permit* ;v C 5 0 � -Sr}1 . Amount ., Permit expires 180 days fium issue date b�.d--1 l cJ(, EXPRESS BUILDING PERMIT APPLICATION________ _.._ TOWN OF YARMOUTH RECEIVEDi Yarmouth Building Department 1146 Route 28 ' : South Yarmouth,MA 02664 ._ ,j `7n1 G : (508) 398-2231 Ext. 1261 N { M` CONSTRUCTION ADDRESS: �� / j Ve-i/r)L ';pcG,r v'y ASSESSOR'S INFORMATION: Map: Parcel: OWNER: Pli 4-e- C,.l(5S t 'r NAME ,� PRESENT ADDRESS TEL. # CONTRACTOR #"J /� '<'0'75 sc/ I--e/c.)C'- 6">r4L Pr� t �'i1%'i G�4z-;2/ AME MAILING ADDRESS TEL.# Residential 0 Commercial Est.Cost of Construction$ /)/G 2 r Home Improvement Contractor Lie.# / �/ 3,i S3 Construction Supervisor Lic.#I z J J% Workman's Compensation Insurance: (check one) I I am the homeowner r I am the sole proprietor 'II have Worker's Compensation Insurance Insurance Company Name: C~ 7/ Worker's Comp.Policy# CS ..5, CJ:� 4 2 e c ;v eI 3? � WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares 2 3 ( )Re ve existing*(max.2 layers) Insulation i Old Kanngs„ighrray/Ristoric Dist. ( ) i- ng like for like Pool fencing _ 'The debris will be disposed of at: 0 12-'2 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 answers) will be just elms..for denial or revoc ion of my license and for prosecution under M.G.L.Ch.268,Section 1. /APPIicant's Signature: Date: //3 `/i. Owners Signature(or attachment) Date: r Approved By: Date: ?`'—J �r. Building i ) EMAI DRESS: / Zoning District: Historical District: Yes -? No Flood Plain Zone: L Yes C No Water Resource Protection District: Within 100 ft.of Wetlands: C.i Yes 1 No CI Yes __ No _ '� The Commonwealth of Massachusetts } �,� 1 �`/ Department of Industrial Accidents t e`/fi=7-: ci, 1 Congress Street,Suite 100 ='J-.`_,=? Boston, MA 02114-2017 `�'" www.macc.gov/din ~`y Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): r i yi-? Kr-' f ns• Address:-51l Z Dive' (;-,/,2k- I S City/State/Zip: -a,/0 - L frtv4 2 i 436) Phone#: S v S- ") GD 2 7 Are you an employer?Check the appropriate box: Type of project(required): 1.i�l i am A rmnlrnrr with / .r..nl...,..e ia.n."...4r . t. . • ,,.._e ...�..,,.,.,,,.�...a...,. . .a....,. 7. 1J New construction 2.01 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. 9. ❑Demolition ❑ ys [No workers'comp.insurance required]t 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.n Electrical repairs or additions proprietors with no employees. 12.0 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.❑ right of exemption We are a corporation and its officers have exercised their MGL c. 14.0 Other � per 152,§I(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. IContractors 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. lithe 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: C 4/ 1 Policy#or Self-ins.Lic.#: LS s.v 65 ri 2 e L./.-1, s)2 i t 1 Expiration Date: .3 /5 /2O Job Site Address: ``I Z .i 13(4.y 1C"'"/ le) City/State/Zip: /(lio 64 /3d„ 'd Attach n copy vf ea.—vwu.wcrs cvTpeas elV_i i"___ u'ecittratitut page(showing the policy number 8$S 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$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I uv aereby ceriry fatter the pains and penalties of pedury that the information provided above is true and correct. Signature: Date: l/3 (/f- Phone#: Svc 7 fx� 2 7 Z IiOfficial use only. DO not write in thi„c area,1n a c rspJj Im r fn n nffin it - '!' J J" JJ City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: r k,,,r.-cline CERTIFICATE OF LIABILITY L Rr INSURANCE r' �'.1° l°" "' f 3/19/1 I THIS CERTIFICATE 18 ISSUED AS A MATTER OF INFORMATION ONLY A$D C4INFERS NO PIGHTS UPON THE CE A:°E HC , ICERTIFICATE DOES NOT AFFIRMATIVELY OR NEQATNELY AMA EXTENQ OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURERSI,AUTHORIZED i. ISEPRESENTAWE OR PROITU ii,MD THE CERTIRCATE HOLDER. IMPORTANT: V the certificate holder Is an ADDITIONAL INSURED,tie pol)cy(Iss)must be endorsed. If SUBROGATION IS WAIVE),subject to Ira sums,&ilia'(mm814005 vi Tile policy,certain policies may returns an entforsernn. A ate mat on this certificate doss not confer rights to the certificate holder in lieu of such srdore.nen(1). fleVEIMBt Schlegel & 8ahi r in ' `Ui MCDOWSLL *ram} egel Ins Brokeir Nn Few (508) 771-8381 a ma: (508) 771-0663 West Yarmouth, 02673 riNim schiegelinsnrance(cmail.con INSUEERIS)AFFORDI13 COVE ! MACS I INSURER A:NAUT ILU8 INSURED INSURER B:CNA M4D-lei REA1'1 ij Matt liG ---- ]_._--_.----.-_---_ CONSTRUCTION INSURERc: � I RE R 0: SOUTH YAIUTH, MA 02 664 INEUREt Ed COVE-RAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY TINT THE POLICES OF INSURANCE USTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD H RESPECT TO WHICH THIS CERTIFICATE MAY BEISSUED OR MAY PERTAN,TTHE INSURANCEOFC)ED BTIE ICTriSTANDING PINY-liEOLANHI,TERM OR COICITIDN OF ANY CONTRAIEIES DESCRIBED HEREIN ISOR OTHER DOCUP,ENTwSUBJECT TO ALL THE TERMS, ( E)CLUSIONS AND CONDITIONS OF SUCH PQUCES_LIMITS SHOW MAY HAVE BEEN_REDUCED BY MAM MA11�e,S ! TYPECr'MYEArlYYOE POUCYNUMaER wirfte INIEWY YI-' 1{ilM RN UNITS A !GENtRALLUAaItITY C. 2.5s4.8741 1 111,0,/?.QV 11 .4J'�!{t ..rr`L�.�.vRRc'Iw'c (o1,000,000"� j ., ]C(Cop.aie ciAL GENERAL LLAB ILITY r D/1AMGE TO RENTED , Ii '' PREMISES(Ea cmnw,o� $ _500,000 , 1 Ci,gwic;;� x;>a i l i I PE RSO AL&*DV INJURY $ 1,00Q,000 I GENERAL AGGREGATE ._ '-T 2,000.000 GEN'LAGGREGATE LMT APPLES PER - P'UL. --�pert. --I ! PRODUCTS-corproP AGG t a 2,000,000 ! B:Y I I.ECT I I LUG i ._ -...__..^.�,.,. 1$ I AUTOMOBILE UAaIUTY ! pip I I 1 (EafkrlELWEfT a ANY AUTO I ` 1 BODILY INJURY(Per pagan) a 1 ALLOWED SCHEDULED AUTOS AUTOS _ I BODILY INJURY(Per incident) $ HIRED AUTOS AUTOSy I !NON Yritt II PkuPti1 Yt1/WAC a .., 1 I S UMBRELLA UAB OCCUR EACH OCCURRENCE I 1 EXCESS L� J CLAIMS-MA0E i 1 I AGGREGATE [:---- 1 DED RETENTION I — 11 B Itetneer ,�. �6S59UB0224N37214 3/9/19 3/9/ao1 ( Am Iorrq+- �WORKERS COMPENSATION IaLtel MN PROPRIETORIPARTNERiEYZGUTIVE �� r r N! DEPICT RMeAe)Efi EXCLUDED? N I A [E.L.EACH ACCIDENT $ 10Q OQO I MIM�endelory in NH) 1 c i ., ��FaM" E;t I rI�1,C(C a !DESLcR N uOF CWRAT1pN3 below I E DISEASE-POLICY LIMIT $ $00,000 1 I El ! : I ! I DESCRIPTION OF OPERATIONS I LOd1T10Ne I V@lCLae Mesh ACORD net,Adetlanal Rounds Schedule.IImacemore mace is ngdaed) TTMt_NTRtY KNATT1'C• v'a UOMIt TO, SSE cevEnz` U i R NT �.¢�� ^^"RrSA I S �.rv.r� \ iV VVAV�Li'il I1ViY �� gyp# POLICY f I I I Cif TiMATE itOi.O R CANCELLATION 11iiiuirio�nr.Ot 7iit A ttio i1e:K:KIs.o POUCEs su CANCELLED BEFORE THE EXPIRATION DATE TIEREOF, NOTICE WILL BE DELIVERED BI ACCORDANCE WITH IRE POLICY PROVISCNS. 1 AUTHORIZED REF#reB! l _ +._ 4 1110E 10 ACORD CORPORATION. All rights reserved. '1 ACORD 25(2010/05) The ACORD name and Imo are rsgistared marts of ACORD Phone: Fart: E-Ma : ' t. Keating Construction 44, Home improvement contractor registration: DATE August 24, 2019 143053 Quotation# 1 54 Lower Brook Rd So.Yarmouth MA 02664 Phone(508)760 2702 timkeating66 u@hotmail.com Proposal for: Job name/location: Mike Gallager Same 42 Bray Farm Rd West Yarmouth Ma 617 645 8704 We hereby submit specificatons and Strip roof shingles off entire house and renail any loose decking Install water and ice shield on lower edges and chimneys Install new vent pipe flanges and 30 lb tar paper on decking Install new white 8 inch drip edge Install Certainteed Landmark 30 yr architectural shingles Install ridge vent at all peaks pp Remove rake boards and returns install Azek trim boards . f'Cc(e /e Remove right front comerboard and replace with Azek . 'S+4c, new SicY05- 4,4r .414SHrif p,r\ S,'c'P S'f‘At�� All debris and trash will be removed and disposed of properly 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. $35.00 per hr+materials if needed Materials guaranteed by manufacturers. Workmanship guaranteed by Keating Construction for 10 years. We propose hereby to furnish materials and labor for the sum of: • (0)o6c) 1/3 payment due at start of job an remainder upon completion Acceptance of Proposal: Date of acceptance: '1 2-i I l5 Acceptance of Proposal: Date of acceptance: The above prices, specifi ti s condi ons are satisfactory and are hereby 1 rliAe ananranwea(tA al0 7/azarAusieet Office of ConsumerAffa•ts&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Individual Reaizti`n 143053 it TIMOTHY KEATING Os/13/2020 D/B/A KEATING CONST. TIMOTHY B.KEATING 54 LOWER BROOK RD. �2 CGQ SO.YARMOUTH,MA 02664 Ye, Undersecretary f Commonwealth of Massachusetts • Division of Professional Licensure Board of Building Regulations and Standards Construction SlIpl4 fysspr Specialty CSS L-099351 ti _,JDires: 05/11/2020 TIM B KEATINGd r ,' 54 LOWER BROOK R® 2. SOUTH YARMOUcTH M 00'126 Commissioner C ""r " r.—