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HomeMy WebLinkAboutBld-20-004745 1' Office Use Only Ds,. .•� © Permit# p ss+, ' H :Amount/610 .CO ,tnr r, t ��'� :Permit expires ISO days from issue date 1BC,.b—OD -- y 7c45- EXPRESS BUILDING PERMIT APPLICA c E j v-E b TO WN OF YARMOUTH Yarmouth Building Department I C - 7 I 1146 Route 28 ��� � South Yarmouth, MA 02664 31 ICI__ �.. P (508) 398-2231 Ext. 126E "ym... ' A CONSTRUCTION ADDRESS: 3 L 1- 0 - 6,,,,✓1,, or V4rii4or..)A Yt,,/ ASSESSOR'S INFORMATION: Map: Parcel: OWNER: ®eo 4-rl/, ivl,✓V) 3 I `� D - 4.7-I/1( Or ye.olq�)NAME PRESENT ADDRESS TEL. # CONTRACTOR: kTe6-71 f --CVL'DlcjeO' {Jr? Rif 4' M- NAME MAILING ADDRESS TEL.# S'Ue,- -26d e ?.' *� ca Residential ❑Commercial Est.Cost of Construction$ `j Sex Home Improvement Contractor Lic.# / 1130- 3 Construction Supervisor Lie.# 7 .35/ Workman's Compensation Insurance: (check one) 7 I am the homeowner E I am the sole proprietor r,i I have Worker's Compensation insurance Insurance Company Name: C._ /1/A Worker's Comp.Policy# 6 5-,5 U 6 D e 2 Y,v3 7?iy WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares 7 Replacement windows:# L/ Replacement doors: # Roofing: #of Squares ( )Remove existing*(max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing i/ *The debris will be disposed of at: \ GJINJ GiJ 1-1. 141t4 Location of Facility I declare under penalties of perjury that . 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 revoc tion o y license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Sty ; • Air-.. Date: 2l2‘ ( 2e) 2U Owners Signa e(or attachment) Date: Approved By: Gam. Date. A•.27 A Building Offic' o i ) ADDRESS: Zoning District: Historical District: {^ Yes _"_t No Flood Plain Zone: Yes C' No Water Resource Protection District: Within 100 ft.of Wetlands: .] Yes 1 No 7 Yes No ' / , rTfAe Wein monweera )(-)74aadad li,tetJe Office of Consumer Aflalls&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Individual . • Registration EV Iration 143053 06/13/204 "' • 1 ..-- i TIMOTHY KEATING D/B/A KEATING CONST. - .., TIMOTHY B.KEATING • 54 LOWER BROOK SO.YARMOUTH,MA 02664 Undersecretary (1---- • • : ,.. Board of of Professional Licensure Commonwealth Constructipo4SISIOdivispr Specialty CSSL-099351 '-•-• t tjtpires: 05/11/2020 r mBmwoldnivingeaRltehgouflaMtiaosnssaacnhdussettatnsdrds -i — 4 yr i f, -,.* '''.4.•-, „-',,..- TIM B KEATING - -..i 54 LOVYER BRg Oft 4 SOUTH YARM kFRof,s1:1164,210.1.\, • s C• 424-- Commissioner --- ( Keating Construction Home improvement contractor registration: DATE January 20,2020 143053 Quotation# 54 L.ower Brook Rd So.Yarmouth MA 02664 Phone(508)760 2702 timkeating66@hotmail.com Proposal for: Job name/location: Deb Allemann Same 31 Jo-anna Dr Yarmouth Ma 02644 508 258 9271 fry.•Nearby submit specificatons and Strip sidewall shingles off backside walls only Install Typar house wrap instal Clem Cedar sidewall Remove 4 St.twindows Install 4 Harvey replacement windows it , 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. Materials guaranteed by manufacturers.Workmanship guaranteed by Keating Construction for 10 years. We propose hereby to furnish materials and labor for the sum of $7,500.00 Balance due upon completon / Acceptance of Proposal- Date of acceptance: //or r /, Acceptance of Proposal: Date of acceptance: ?SI L.a The above prices, specifications and conditions are satisfactory and are hereby accepted. The Commonwealth of Massachusetts Department of Industrial Accidents _c:l11_ I Congress Street, Suite 100 % j_ Boston, MA 02114-2017 V*..�;j 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):` /�,01 eoe7 jl f _ _a Address: Stj 2 (`err),L p City/State/Zip: �/c/"hl chi h. hit Phone#: 24:0 Z 7 oZ Are you an employer?Check the appropriate box: Type of project(required): l.�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. Er any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑Demolition 10 Building addition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workei-s'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. 13.Q Roof repairs These sub-contractors have employees and have workers'camp.insurance.: 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q Other 152.§1(4),and we have nn emnlny►rc.FNn worker? *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. :Contactors 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.--4/4 Policy#or Self-ins.Lie.#: tS S C y��o az t,v 3 7 zi y Expiration Date: 3/S /Ea inh Site.ArlrlrPec j Jo Grn C �� lotvir�..._in p. �w/e.ifz G`>��.e�y i u w�.0 Lap. 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: Z 2d f ed ZO Phone#: S U ef' 760 - 2 7 Z _ 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 Insnector 6.Other Contact Person: Phone#: A d CERTIFICATE OF LIABILITYDATE °INSURANCE 3/19/19 THS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFEW ATWELY OR NEGATIVELY AMEN), EXTEND OR ALTER TIE COVERAGE AFFORDED BY TIE POLICES BELOW. TINS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING NISURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AME0 THE CERTIFICATE HOLDER, IMPORTANT: N the certificate holder is an ADDTONAL INSURED,the poNcylies)neat be endorsed. If SUBROGATION IS WAIVED,sulsject to the terms and conditions of the policy,certain policies may require an endorsement. A*element on this certificate does not confer rights to the certificate holder in Neu of such erdore nengs). FRODuM Schlegel i Schlegel Ins Broker Mr" JULI - III 34 Main Street 'PHONE NI><e (508) 771-8381 IIaI; t508I 771-0663 West Yarmouth, MA 02673v;� achlagelinsuranceegaail.e� M+aWlRmAFFa100$3 COfERAQE NM r NlsuReo a Mesa A:NAUTILtlg INeuReIeTIMOTHY KEATING DBA KEATING C:CNA CONSTRUCTION INSURERc 54 LOWER BROOK RD MM+IBQ' MIAMMU;. SOUTH YARMOUTH, MA 02664 COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICES OF INS RANCE USTED BELOW HAVE BEEN ISSUED TO THE INSIdiED NAMED ABOVE FOR THE POLICY PERIOD NDCCATED. NOTWITHSTANONG ANY REQUIREMO4T,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHCH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, 1N�EX L USONS AND CONOTIONS OF SUCH POUCIES,LIMITS SHOWY MAY HAVE BEEN REDUCED BY PAD CLANS 11t MY I�L TYPE Oi INfiIRIY/CE ��� ► - �cyy��p � A ��LIAaLtfY I work Pawnw men iAReAIDIYta,(IeeAferYmiL UNITS GL 2548741 3/19/19 3/19/20:EACH OCCURRENCE f 1_,444,000 X COSIEPCIM GENERAL LMBIUTr MaoasnDr,cU._ $.__ 504,.Q00_ j CtAIMSNWIDE I OCCUR . 4E DEW(Are ore person) S 11) Q00 i , , . PERSONAL&AnvINURY i s 1,000,000 i f GENeau AGGREG±ITE is_,- 2,000,000 GEN`L AGGREGATE L M T APPLES PER 7 ' PRO. pRooucrS,COIIQ,oP ACC.^f 2,000,000.._ • i POLICY, , ECT ' . .I LOC I$ AIITtIMOeILe LLialI1TY OWNED SINGLE LIMITJ _IEa ecaosr/i, ANY AUTO _...._ $ ___.... ..__ ....._...__.._. AALL OMR UTOS D ACNDCNNEDSIAED BOOiIY INJURY(PrDssan) .:$ SODA Y INJURY Mot aouerd) f FARED AUTOS AUTO PROPEFh bAPAAGE UMlIEIlA llAa 1 f �1 OCCUR EACH OCCURRENCE $ 1 EXCESS LIAO CLAIMS-IY M AGGREGATE f DEQ RETENTION f i _._. B ANDrlafPLOYeR COMPENSATION ;6859UB0224N37214 3/9/19 3/9/20 i 1 we STATu- f OTH-)f ANY FROPRIEIORMARTNEghAECUTNE i N t A ;EL.EACH AC j X.J-SDRY1rIQli ---`-Fg- .....�. OFFICE MEMBER EXCLUDED? Q(,lit $ 109,000 M+udebY M NH) ,EL DISEASE-EA BgLOYEEI$ 100.,000' tOpCd 6uOERAtONS ,._ wow 'E L.DISEASE POLICY i.Wr i$ 500.000 i DESCRIPTION OF OPERATIONS/LOCATIONS/VEMCLEe MAN ACORD let,Ad 10N1 Illenwls Schedule.a won Alma Is regYIND TIMOTHY IDEATING HAS ELECTED TO BE COVERED UNDER HIS CURRENT WORKERS COMPENSATIOIaf POLICY - CERTIFICATE HOLDER CANCELLATION ... SHOULD ANY OF THE AaOVE OE ammo POLICES EE CANCELLED SWORE THE EXPIRATION DATE THEREOF, NOTICE MU. SE DELIVERED N ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED TIE 14111r0/ ACORD IS(201 Wt?S) The ®1MU , 10 ACORD CORPORATION. AM rights reserved. AC ORD name and logo are registered marts of ACORD Phone: Fax: E-Mail: t