HomeMy WebLinkAboutBld-20-003659 £Office Use Only
Oif.X
$' % Permit
t�� C ;
01 - � s,iimonnt
��
Permit expires 180 days from
�► issue date
•
EXPRESS BUILDING PERMIT APPLICATIO µ '1'
TOWN OF YARMOUTH
Yarmouth Building Department !T, `; A "� ``
1146 Route 28
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS: ilt)Ccv/'15 L yei.,,,,,,-,_, vy-d O 266>
ASSESSOR'S INFORMATION:
Map: Parcel:
OWNER: 0/1 ,r P Lw LtAAler1 q !r 0Ali:d SF` �G41Il DZis
NAME � PRESENT AD RESS f ye7,7“)/Z-
AME TEL. #
CONTRACTOR i2T i'17c7"") S(>l L i ,- ( � fee'MAILING ADDRESS TEL.# �,:s..— Zco 2 7l
Residential 0 Commercial Est.Cost of Construction$ !( Sc,t)
Home Improvement Contractor Lic.# 1 .53 Construction Supervisor Lic.# 55 S-r,
Workman's Compensation Insurance: (check one)
❑ I am the homeowner /r I am the sole proprietor ❑ I have Worker's Compensation Insurance
Insurance Company Name: CA/4 Worker's Comp.Policy# 65S -4.' Oct 174.1 3 72›.
WORK TO BE PERFORMED
Tent Duration (Fire Retardant Certificate attached?) Wood Stove
Siding: #of Squares Replacement windows:# Raeplaeement.doors _#
Roofing: #of Squares I ( ,emove existing*(max 2 layers) Insulation
Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing
*The debris will he disposed of at: 4/�l✓/4 t/" AtCi4
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 revoocc,noon of my license and for prosecution under M.G.L.Ch.268,Section 1. /
Applicant's Signature: _— Date: l eigi/if
t b
Owners Signature(or attachmen ) Date: p
Approved By: !mil fi Date: / 1'4/
B ' 0 tat(or designee) ADDRESS`
Zoning District:
Historical-District: 1 Yes A No Flood Plain Zone: Yes C No
Water Resource Protection District: Within 100 ft.of Wetlands:
L Yes 1 No 7 Yes 7 No
_ The Commonwealth of Massachusetts
*=, 1— t Department of Industrial Accidents
rat=,y I-Congress Street,Suite 1-00
It i == Boston, MA 02114-2017
*... E- www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please PrintLegibly
Name (Business/Organization/individual):/1t-j kFfA .yl
Address:Sy j,, ,f fr.j 2) ,er
City/State/Zip: Xigia.gz-,
� �? Phone#: J + )6 ) 2-7eIP
Are you an employer?Check the appropriate box:
Type of project(required):
1.]I am a employer with I employees(full and/or part-time).* 7. 0 New construction
2.❑I am a sole proprietor or partnership and have no employees working for me in 8:121 Remodeling
any capacity.(No workers'camp.insurance required.]
"s. I am a homeowner doingall work myself. t 9. ❑Demolition
❑ y jNo workers'comp.insurance required.]
4. I am a homeowner and will be 10 Building addition
❑ hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions
proprietors with no employees.
12.❑Plumbing repairs or additions
5.❑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 14.❑Other
152,§1(4),and we have no .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 amplyhave=playacts,.they mua provide their workers'gip..policy der.
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,/!/ ✓�
Policy#or Self-ins.Lie.#: b S �hg/92? LjN37 2/
. `1 Expiration Date: / /2
Job Site Address: q'j io1iv, 5-}- City/State/Zip: e,/ c,J� 4-1--
Attach a copy of the workers' compensation policy declaration page(showing the policy nu>diber 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 certi and the pains and penalties of perjury that the information provided above is true and correct.
Signature: Date: /2./i///1
Phone#:
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. Ph4mh:no lncnarinr
fa.4O er _ToqfilltePt `b- �rti«,,,
ersoel — - "Phone#: - -r ... -.� -b -r--....,,.
Phone#•
_.---- -1
Ad—v-1w? cERTIF lcATE OF ukaguiTy iinuR 444E4m
3/19/1
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATIoN ON/v Akin couciEss He atom Lipopti THE.e...ERrImATE pAii,ma Thje
CERTIFICATE DOES NOT AFFIRMATWELY-OR-NEGATIVELY AMEND EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICES
-BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING,ISEUREEHSL-AUFHDREED
FiErITATIVE OR PROiiirUkk,Are)'IHE CERTIROATE HOLDER.
- : the cc cate holder is an DD I RED, the policAss) must be endorsed. SU All IS WABER.subject to
aisi iisfirra sIII4u4a1uliions cif jile PoiCY.c•rSaill POaCieS May ressunkaa,socioreement-Astaawnest on this certificate does not confer rights In the
ceitlicate.holdar-in-beu-of-such ervior .
_
civc.vmvfcgt
--SAW:— _JULI -MCDOWELL ___
1 Schlegel A Schlegel Ins Broker
14 m..lvin. 14.0.rme+-
6-3-
- A : sch.1 linsurance "1.com
West Yarmouth., -MA 02-673
• - - —
-
1-INS LINED
INSURER e:CNA_ i
I Zreliirirt /CEA Trek; Disis ITEAt 1.66;
CON SIL 2vULTION INSURER C:____,
_,__W!IENIRsu_________
54 LOWER BROvic KO
1,,M fo_i_R E: _ _
SOUTH -YARMOUTH, /4A 02664
INSURER V:
---. -
COVERAGES .CERTIFICATE-NUMBER: ---Th-----n---Fr---------.-4ION UMBER:
THIS IS TO CERTIFY THAT THE POLICES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE-POLICY PERIOD
INIJICA I tu Nu'YYI I Ilb I ANUINLI PrIT HeQUIREMENI, 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.
twr
Exa.usiONS AND CONDITIONS OF SUCH POUCES_LAM SHoimki MAY HAIN eF_ENBEnumo BY Pain(1.AIM __-- •
TYPEOF INSURNKE -AIIIWIRINV --
t
POU CY NUMBER 1 P WF 1- "OilCio.EV
LINTS , _
GENERAL I.MOUT Y
#77 2R- 974,11 litaii CL 1./1,411•14. ...........--
LL 1 Ciag,.4...y:D_
r-----]
trAMENTED ; -I
1 X I COMMERCIAL DENEML Losturr [ I
_PREMISELlapccucemi`eL___ ______39.Q.J1QQ__
'771-1 (K. I, ‘1,-
,._; -•:-...s2 I ,
1 I
i I
I '
I i
tXNERAL.AGOREGAT,E, -9 2 000 000
GENIAGGREGATE llitTAPP LIES PER I
kRODUCTS-COLIP/OP AGO S 2 000 0
IPULCY : I L(X
$
AUTIBIOWLE UAINUTY
,_g____
' ANY AU-113
i ODILY INJURY(Per person) $
__ ____________
L OWW D SCHEDULED
;BODILY INJURY(Per acciden) $
Amos AUTOS
ISMI- 174 .:
____
k_, HIRED AUTOS ^. t:"AUTO'S'
' 1 i_r_ltr_ptc_twi_ c.c±dentivitr________ _________
______ -___. $
UWIREUA LIND [....0 ccuR 1 I
1
. EACH OCCURRENCE S
, 1-EXCESS LIAII .
CIAINS-MACE f
11----AnonEGATE-------------s '
DED RETENTION
. B -WORKERSCOMPE WAIN*
i 6S59UB0224N37214 3/9/19 3/9/2o x 1,wc sail); 07,ti-.
.•14"."44 DrizRE'" .**.•;'!"'
TSAI;
....,....._ ..--.......4_
ANY PROPRIETORPARTHERB xecurnm ----1,• ocscsaresieEn EXttOED,
i
Wandstory in NH) .1_7 FRIA
1 1,Ek..EACH ACNF $ 100,OQQ
.
1 gerAPTIOblei OF OPERATIONS_ vr : r ________
1 EL.DISEASE-POLICY LAIR' SOO 000
I
' I
l
III I ;
, I
CESCRIPTION OF OPERATIONS/LOCATIONS/4E64CM.Medi ACORD 101,AddlOons/Reseda Schedule.*more spice Is required)
' m Tlarvestv rrerev.rua Fece, r_Y v./smart TO LW ACCE.4712p11T1 rtr.Eze Itivz cure...pm, .0,,,,,,,,a...=. ,,,,,, . trzAlmrdx wizil.........r
.1
.
1
CER i slug r t ritxutit
_CANCELLATION
.
SJii)iii_li ANT cm;.3HeAtikivE U6sukitsED PuLICES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DEUVERED IN
ACCORDANCE WITH TILE POLICY PROVISIONS. .
AUTHORIZED RE
.._ .
I . _ \?,-itdi
ID 19138 10 ACORD CORPORATION. All rights reserved.
ACORD 25(2010/05) The ACORD name and Joao are reolsteredmarks of ACORD
Phone: Fax: E-Mail:
Keating Construction
Home improvement contractor registration: DATE December 20,2019
143053
Quotation# 1
54 Lower Brook Rd
So.Yarmouth,-MA
Phone(508)760 2702
tirnkoating66 ahatm ail corn
Proposal for Job name!location:
Mari Lou Whalen Same
9 Mulford St
"Yannouth Ma'02654
774 573 7210
We hearby submit specificatons and
y�.`vul 54 4Nh,
�yt�
mow.,
r�t Q
e ...x:ur.,t ,sr.:->,en. e<.,ex+{ ..+'Iitd rn t.vt ✓�1¢e ... .:,..r':".,. ., i rn i t r z a r
u..nrn« ..w . az, ... ...._. x,Je r.i.-,Lx«v •d„dE„.
Strip roof shingles off entire house
Install ice+water shield on all lower edges and chimneys
laastall.30-1b•tar.paper.on..entire.roof
Install new vent pipe flanges
Install white F 8 inch drip edge
Install Certainteed Landmark 30 yr architectural shingles
Install ridge vent on entire peaks
Repair lead on right side of chimney as needed
All debris and trash will be removed and disposed of properly
..k ifs }'^fFw y�T �F„yv, :i 1a P..a•i..� '1 Ii Yf'. }t ', ry,. '1 Y,:`i:... MA fG: 1tt �., Hs4j
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.
y11s,.pdrgpnse hereby to furnish materials and labor for the sum of.$7,500,00
Balance due upon completion
Acceptance of Proposal: Date of acceptance: ( 2-s I i 5
Acceptance of Proposal: Date of acceptance: /2(7 A, / 15
The above prices, specifications and conditions are satisfactory and are hereby accepted.
n�3e mrnainaoecr fit a. 2 i6Jdarktie//.t
Office of Consumer Anal Business Regulation
j HOME IMPROVEMENT CONTRACTOR
' TYPE:Individual
Registration Expiration
/ 143053 06/13/2020 --"*.,
TIMOTHY KEATING
D/B/A KEATING CONST.
TIMOTHY B.KEATING
54 LOWER BROOK RD.. -
SO.YARMOUTH,MA 02664
Undersecretary
•
Commonwealth of Massachusetts
Division of Professional Licensure
�
`'-• // Board of Building Regulations and Standards
Constructio{t�5i�fir Specialty
CSSL-099351pires 05/11/2020
TIM B KEATING i L
• 54 LOWER BRg�O�
SOUTH YARM
h
Commissioner