HomeMy WebLinkAboutBld-20-003534 �Og�� � Office Use Only
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3�' a Permit expires 180 days from
t issue date
EXPRESS BUILDING PERMIT APPLICA' ON
TOWN OF YARMOUTH
Yarmouth Building Department i"
1146 Route 28 ������Q
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS: 2 6 , e-A_SL:1 L -J •4 r"r,1 t- 7 /%Vy`?'
ASSESSOR'S INFORMATION: I((
Map: / Parcel: `/
OWNER: TO n t)C r/-�; L (�'f h;SG.� t' /" yi. iiA-47 h C-,-,,,
NAME PRESENT ADDRESS / TEL. #
CONTRACTOR:-11-a 1 J( fi ,) SL/ / L-ti_:'C- (�1 Ccl1_ C Yei rr k't/( '24(3
NAME MAILING ADDRESS TEL. hccc,
ed
r1tesidential 17 Commercial F,st.Cost of ConstructionS /0
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Home Improvement Contractor Lie.# I /JO i 3 Construction Supervisor Lic.# %S:,?,S7
Workman's Compensation Insurance: (check one)
❑ I am the homeowner L I am the sole proprietor ./I have Worker's Compensation Insurance 1)
fncnrancr C'hmna m ny Nar�- _ A/4 W rkr.r',s Comp Pc!icy# 6 S 5 0 2?f/jl))Z/ '
WORK TO BE PERFORMED
Tent Duration (Fire Retardant Certificate attached?) Wood Stove
Sidinw: #of Squares Replacement winrinwc:# Renlaremvnt rinnrse ii
Rooting: #of Squares 20 ( )Reiove existing*(max.2 layers) Insulation
Old Kings Highway/Historic Dist. ( )Replaing like for like Pool fencing
*The debris will be disposed of at: r ili/AJ
(( 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: � ----- Date: i 2)23//5
Owners Signature(or attachment) Date:
'/ ` Date: \� �3_1'Approved By: �/ __in..
6:::2
Building Official(or designee) EMAIL ADDRESS:
Zoning District:
Historical"District: 1 Yes 0 No Flood Plain Zone: Li. Yes G No
Water Resource Protection District: Within 100 ft.of Wetlands:
11 Yes 1 No 7 Yes No
The Commonwealth of Massachusetts
Department of Industrial Accidents
` }ct= Boston, MA 02114-2017
.�,, www mass.gov/dia
\Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Annlicant Information of,,, n_:.,. r .;b,_.
Name (Business/Organization/Individual): I t'/ 4'(c-
Address: S C)t�a<'� �(r1J2/ Pc)
City/State/Zip: `Armco i'/A 02K( Phone#: -o Cf.' ) ?)az
Are you an employer?Check the appropriate box: Type of project(required):
1.21 I am a employer with ' employees(full and/or part-time).* 7. ❑New construction
2.0 1 am a sole proprietor or partnership and have no employees working for me in 8. ..'Remodeling
any capacity.[No workers'comp.insurance required.)
Q ❑nprnnlitinn
3.❑i am a homeowner doing alt work myselt:[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.❑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'coma.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,§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.
Contractors 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 Pmrinveea the'must i ro"idn their
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: _.i1/A
Policy#or Self-ins.Lic.#: CIS .55.v 6 022 t7 dam.')2/ Ex„ira+:nr.rate: . S2 U
Job Site Address: 2 Assn k. City/State/Zip: VL'/YJafi- ( ,4 ) >
Attach a copy of the workers' compensation p Icy declaration page(showing the policy nt#mber 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$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify un er the pains and penalties of perjury that the information provided above is true and correct:
Signature: Date: l2 ) 1 / 5
Phone#: -r0 76 d 47
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
__ -issuing Authority(direle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
A4✓'n tl'IF CERTIFICATE R.r+ dw�rRr
t+CR 1 I1F`I1Arr,1'�1 E OF LIABILITY T • INSURANCE r► -<--
I 7 F!S CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION A[ItY 3/19/1
Ties
I 114SC RTIF DOES NOT AfFMiIFATIVELYATI R N INFO MATELY pip ram_ n .2aTQ iw►H'HE C`RnRcAlE; v
BELOW. THIS CERTIFICATE OF INSURANCE , EXTEND OR ALTER THE COVERAGE AFFORDED .� .R
BELOW.T}IS li I- .__ . DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING THE POLICES
PROD Ji:t.K,MO`I"it CERTIFICATE HOLDER. RER4SI AUTHORIZED
1M ANT: 1 the co cats holder is an
:wren*do cuthui>euuns vi illy _ _ I RED, lie policy(es) must be endorsed. SU ATMON IS WAIVED,cerliic" holder in Ieu of such endorscme Ioscies mat► aMt anferr rights
subjecto t;Alo
A statement on this certificate does not confer rights to lie
oo..n0rEo
SchlegelI
PHONE
& Schlegel Ins Broker : --JULI_ 77A1-83 �x N ; (SOs)LL
I Main Dt roe!- ----
0 771-06ti3
West Yarmouth, MA 02673 Xb € : schl linsurance
1-com
INSUIRI FtiS1 AFPORplN3
INSURED a�IIRERA:NAUTILUS
INSURER
B:CHAAu9V 11a L AAltlt Q A "ATIIV(
CONSTRUCTION •,MrnNR c: -
INSURBR�- —.._
54 LOWER 132tUUlC l2tJ -- _-
SOUTH YARM OUTH, MA 02664 I RER E: _ _------ ---
i
COVERAGES
RA6E$ 1NBk1REtF: - --`"_ _-.--
r Is TO CERTIFY THAT THE CERTIFICATE NUMBER: REVISION NUMBER:
POLICES OF INSURANCE USTED BELOW HAVE BEEN ISSUED TO THE WSLREO NAMED ABOVE FOR THE POLICY PERIOD
irVua,H ri1r. niu iVW i tea i pnuiVl PM ttkGlUlheEMMkN 1, TERM Oft CERTIFICATE MAY WE ISSUED OR MAY PERTAN, THE 1 COMMON OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
EXCLUSIONS ANDCONOITIONS OF POLICIES INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
NSR i "-' _.._.- • I.NBTS SHCMIN MAY HAW BEEN EEOJCED BY PRIn if A.ARA%
LT__R r ,. TYPE OF INSURANCE � I..
. tauc;�ice..
A i GENERALLYVsl17Y
PoucY NUMBER
P
;XX COPMERCIAL GENE ,_,..
naitcZA1 ?/t4L�ar UNITS
zltat?n
FWL LIABILITY
`�\•�... ww�incv:c
��a�.c.a w"� I v I DAMAGE TO RENTED - i �V
IP�tFa- _ s 04.000
?ICU
—� lruiYcM parsvi) i j- l�U
_i PERSOIWL$ADVINJURY !f 1 000 OO
CEN'I.AGGREGATELENTAPPLIESPER E j•
GENERAL AGGREGATE }s 2 000 000
. --1 ppm r"
rvLa r : Luc
PRODucrs-OORrPrOP AGG f 2 000 000
AUTOMOBILE LWBIUTY i f
N
1 ANY
1 (Ea a__ _ 3t)
Al I O WRE D AUTOS O ( j 80DILY INJURY(Per peBon) $AUTOS
WRFC AUTOS AUTOS"C ! I I NJ' INJURY(Per oxidant) f
r'rtV�ra'ttF UAMAGE s
-
� ) UMBRELLA LIAR ----.
OCCUR -_______I—
I EXCESSLIAB_ CLAIMS-MADE) i + EACH OCCURRENCE _
DED RETENTI f ----r + I I !AGGREGATE § ._._..-___-_-
1 WORKERS COMPENSATION l._—_.
B "PIranzfre"w•"7" I6S59IIB0224N37214 3/9/19 3/9/20 STATu O7H — A�
1 I NNPROPRIETORrPARTNER;EXECUTI E r r N i ; $r,WC. ..,_..
OFFICERMIEMBER EXCLLDEDI f = - - '�`
pAandabry in NH) N!A [E.L.EACH AC,�0E.Nr 10Q 000I
grikA
c e n ��`yi • tart fllt_ OF OPERATION t9 +H r Et.DISFSF_POLICY LMR j0Q Oo_ __—_--- _
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DESCRIPTION of OPERATIONS!LOCATION!VEHICLES j(Mash ACOM1101,Additional RRemotas Sd»duN,anion space is rsgdad)
TrMnIntv FirlimTNa HA !-LECTEr TO
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I
OEN!iFICA f E ttOLUEN
CANCELLATION
oemAJLD ANT R.M. Mt 1AMPYt OeSi tetitO PCIUCI ES BE CANCELLED BEFORE
I THE EXPIRATION DATE THEREOF, NOTICE WILL BE D
( ACCORDANCE WITH THE POLICY PROVISIONS. DELIVERED N
AUTHORIZED RE
I
0 1988,2)10 ACORD COR
ACORD 25(2010/05) The ACORD name and lotto are registered PORATION. All rights reserved.
marks of ACORD
Phone: Fax:
E-Mail:
Keating Construction
Home improvement contractor registration: DATE December 18,2019
143053 _
Quotation# 1
54 Lower Brook Rd
So.Yarmouth MA 02664
Phone(508)760 2702
Proposal for. Job name/location:
John Perry Same
26 Erickson Way
Yarmouth Ma 02664
617 529 8096
We hearby submit specificatons and
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Strip roof shingles off entire house and renail any loose decking
Install Certainteed Water and ice shield on lower edge, walls and chimneys
Install Certainteed.Roof Runner paper
Install new white 8 inch drip edge and new vent pipe flashings
Install Certainteed Landmark 30 yr architectural shingles Hurricane nailed 6 nails a shingle
Install Certainteed Air vent 2 ridge vent on all peaks
Remove rake boards and install Azek Trim boards with screws and plugs
Certainteed 10 year sure start protection included
i - c'4-11 pubA Peol&i
All debris and trash will be removed and disposed of properly
" b. c ',"A P µ • SSrY v5 A'W4 } l y i A t 'ti 1 r1 f l,,1 `.. '..
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.
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ra r1.411- 16 wr fwrt»t',11401 auu n�wueus f o is sour o $wwvv.00
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Commonwealth of Massachusetts
;�J Division of Professional Licensure
j f Board of Building Regulations and Standards
Constructiioo-SSI F`hior Specialty
CSSL-099351 j E,5 ires 05/11/2020
r t r
TIM B KEATINr Z a
G �, I A.
54 LOWER w`r
SOUTHYARMOt1H ;"
Commissioner
Ci
'n�L�avaac/%u;tel�v
C3'�e oo1e�xonuretcl &Su'P. ss Regulation
Office of Conwmer Ada"' CONTRACTQR
HOME IMPRTYP M Ind
�.,
143053 06113/2°2° .1\ '
TIMOTHY KEATING CONST.
DBIA KEATING
TIMOTHY B.KEATING 6
54 LOWER BROOK RD.- ' Undersecretary SO.YARMOUTH,MA 02664
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