HomeMy WebLinkAboutBld-20-005037 Og Yl(Ai- ' ice Use Only e6/7
' Amount
•
Permit expires]80 days from
"` issue date
EXPRESS BUILDING PERMIT APPLICATION FM , ,-
TOWN OF YARMOUTH -. .
Yarmouth Building Department I ; N r
1146 Route 28 ; i 1� �;3 ?4?u I
South Yarmouth, MA 02664 / 4 _' ,/
(508) 398-2231 Ext. 1261N' rdr
CONSTRUCTION ADDRESS: 'j(� ( i./t/,r1-43. � j \f(-K 1 uu-t"L, i'
VI-
ASSESSOR'S INFORMATION: r/ J
Map: Parcel:
OWNER: v UO .?v) (, C Ci iJ C f✓< ; �-. -. /L4 ,J, v ',!i, -N t,-1,4
NAME PRESENT ADDRESS ( /TEL. #
CONTRACTOR: NLEAl k"S 1.'7 1) , G'U1,1i C .l J -
ri r /rk„,f /- 1
L ;
MAILING ADDRESS / EL.#_jj fi G. � ' `b,
.r.1 Residential 0 Commercial Est.Cost of Construction$ t 1 }/sJ ri_y
-1
t y(. '
Home Improvement Contractor Lic.#
s> Construction Supervisor Lic.# r) �YI-/
Workman's Compensation Insurance: (check one)
I am the homeowner 7 I am the sole proprietor ill have Worker's Compensation Insurance
r_�
Insuranct!/eb p y Name: 3.> U ;J 22?-1 ✓_) !2 1 y Worker's Comp.Policy#
WORK TO BE PERFORMED
Tent Duration (Fire Retardant Certificate attached?) Wood Stove
Siding: #of Squares Replacement windows:# Replacement doors: #
Roofing: #of Squares 7 ( ( move existing*(max.2 layers) Insulation
Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing
'The debris will be disposed of at: 4--.Gs t(,,;ill, 144,'4
Location of Facility
1 declare under penalties of perjury that the statements herein contained are true and correct to the best of my knowledge and belief. 1 understand that any false answer(s)
will be just cause for denial or revoca ion of icense and for prosecution under M.G.L.Ch.268,Section 1.
Applicant's Signature: r' ----12f Date: Sri I i / tj
Owners Signature(or attachment) _ sa Date:
Approved By: Date:
—/2-10
13 ' in ci or designee) E ADDRESS:
Zoning District:
Historical District: 7 Yes _7 No Flood Plain Zone: Yes L No
Water Resource Protection District: Within 100 ft.of Wetlands:
L Yes 1 No 0 Yes _ No
. The Commonwealth of Massachusetts
} =, 1— I' Department of Industrial Accidents
,lIZ_ 1 Congress Street, Suite 100
'Slij= Boston, MA 02114-2017
��;, " www mass.govldia
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 6/ K?>._; 1-1'. iI
Address: 5
City/State/Zip: '=-7�,,A)/-, /1-c4 Phone#: 5 rsti - 2 K (- e 7 0Are you an employer? heck the appropriate box: Type of project(required):
1in I am a employer with / employees(full and/or part-time).* 7. ❑New construction
2.❑I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling
any capacity.[No workers'comp.insurance required.]
3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
9. ❑Demolition
10 ❑ Building addition
4.❑I am a homeowner and will be 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. 12.0 Plumbing repairs or additions
5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet U.❑Roof repairs
These sub-contractors have employees and have workers'comp.insurance.t
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.El 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.
tContractors 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 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: (_ ,r./ 4
Policy#or Self-ins.Lic.#: 4 5 51'i c' 6 L, e 7•L"5 /21 c! Expiration Date: ?15 / 2j
Job Site Address: i16 ( t- -"� 4.7:2 y-''',, City/State/Zip: `/4 iL le`-t t, 6 L 4-1
Attach a copy of the workers' compensation policy declaration page(showing the policy nu ber 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: Ti //kc
Phone#: > C 7f G 6 76 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 Inspector
6.Other
Contact Person: Phone#:
]L?\
NOTICE - NOTICE
TO — _�� TO
EMPLOYEES = _ _ EMPLOYEES
y •4W
o =14 sv s
The Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
LAFAYETTE CITY CENTER, 2 AVENUE DE LAFAYETTE, BOSTON, MA02111
(617) 727-4900 — www.mass.gov/dia
As required by Massachusetts General Law, Chapter 152,Sections 21,22&30, this will give you notice that
I(we) have provided for payment to our injured employees under the above mentioned chapter by
insuring with:
CNA INSURANCE COMPANIES
NAME OF INSURANCE COMPANY
P.O. BOX 4614
BUFFALO. NY 14240-4614
ADDRESS OF INSURANCE COMPANY
(6559(18-0224N37-2-20) 03-09-20 TO 03-09-21
POLICY NUMBER EFFECTIVE DATES
'emmm SCHLEGEL & SCHLEGEL INS 34 MAIN STREET MA-28
0=
YARMOUTH MA 02673
NAME OF INSURANCE AGENT ADDRESS PHONE#
0�
KEATING, TIM DBA 54 LOWER BROOK RD
_ KEATING CONSTRUCTION
0� SO. YARMOUTH
MA 02664
EMPLOYER ADDRESS
EMPLOYER'S WORKERS COMPENSATION OFFICER(IF ANY) DATE
MEDICAL TREATMENT
The above named insurer is required in cases of personal injuries arising out of and in the course of
employment to furnish adequate and reasonable hospital and medical services in accordance with the
provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the
°— injured employee. The employee may select his or her own physician. The reasonable cost of the services
provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably
connected to the work related injury. In cases requiring hospital attention, employees are hereby notified
that the insurer has arranged for such attention at the
NAME OF HOSPITAL ADDRESS
004830 w2OP1G15 TO BE POSTED BY EMPLOYER
•
• Keating Construction
Home improvement contractor registration: DATE March 11, 2020
143053
Quotation# 1
54 Lower Brook Rd
So.Yarmouth MA
Phone(508)760 2702
fiimkeating6 t,(athotmaii corn
Proposal for: Job name/location:
Owen O' Rourke Same
96 Captain Noyes
South Yarmouth Ma
We hearby submit specificatons and
Description
Strip 2 layers of roof shingles off entire house
Install ice and water shield on all lower edges,valleys and chimneys
Install 30 lb tar paper on entire roof
Install drip edge
Install new vent pipe flanges
Install Certainteed Landmark 30 yr architectural shingles
Install ridge vent on all peaks
All debris and trash will be removed and disposed of properly
Only items specified above are included in this proposal.
Rotted wood replacement 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: $12,500.00
Senior Citizens discount included
Balance due upon completion
,)
Acceptance of Proposal: Date of acceptance: .:, 1 1
Acceptance of Proposal: (?r,4 .� t , e i.- Date of acceptance: o d/
The above prices, specifications and conditions are satisfactory and are hereby acceptd'd.
CtER 1 ;F;CA it E OF LTA _�. •TY wisely
NS R`hicE
!Ms CERTIFICATE IS ISSUED AS A MATTER. �ILI 1 � 1�,�1"(�{ ontel�Joornr�
CERTIFICATEOF Wow!/ATIQN OM1y aMn cl_ FFacf29/I
I NOT AFFIRMATIVELY OR Tty y AMEND, ' Mnµn �eanu �.c ,�,E.^,
BELOW. THIS DOES CERTIFICATE AFFIRMATIVELY
IR ATIVEL INSURANCE O DOES MOT CONSTITUTE T ICJ OR ALTER ---.-
S
THIS t Cm YCiiuui t TTE COVERAGE NG INSU D IS TAU P0t1C1ED
►i,#NU`irk CERW*CATE HOLDER, CONTRACT BETWEEN 7}tE 1SSUtNG iNSURERtgF� AUTHORIZED
IMPORTANT the cord cafe holder la an ADDPt10NAL f
IMPORTANT:
ilik aerirpi aria r:tithe c rrd c is older certain A RED, be pollcy(ies)must be endorsed. If SUBROGATION certificate holder ni ii u of such eMo praiiCy,certa policies y require an o IS WAIVED sus oct to
,.n,,rao X�• seRlent a statement on this certificate does not confer rights to the
Schlegel & Schlegel Ins Broker •_JUWELL
LI
West Yarmouth .,PHON 08 771-8381 T , (508) 771-0663
. •MA 02673 a schl elinsurancee il.com
_ INSURE S AFFORD!
INSURED — _.- --_Ki COVERAGE j
INSURER_NAUTILUS NAIC k
1�'Yvlttl `-- INguRt3tB:CNA°► tSL'111'LtVts —
CONSTRUCTION INSURER C
54 LOWER is tC)Ort L U
_INSURER_ 0; _
SOUTH Y
ARMOUTH, MA 02664 INSURER E: —_- _-_--
COVERAGESINSURER.CERTIFICATE N R F: j
THIS IS TO CERTIFY THAT THEUMBER:
THRIOD
IS H r TO POLICES INSURANCE USTED BELOWREVISION NUMBER:
NO 1 IF i IyS i T THEt,POLICIES
ES OFtINSUR I, TE12M OR CONDITION OF ANY C
HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY TO
THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE 1 CONTRACT OR OTHER DOCUMENT WRH RESPECT TO WHICH THIS
EXCLUSIONS AND ORMAY
SUCH INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS
LT R ._ - - POLICIES_LIMITS SHOV;t�MAY HAVE F E1+l12EIlIJCFt�RY Pssln f 1 Aar SUBJECT TO ALL THE TERMS.
LTR TYieEOFINSt INSURANCE
IDLUtift
POLICY NUMBER
mmluvrTyry
umrs
A ' GENERALLIA81LTry OFF i l3O11
X'COMwERClALGENE /�Q/�a �1�p1�n
--{ .� GENERAL
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^!a:aac,: .DE I v n.....cn. j UAAA4GE TO RENTED ?—1 l.V u V. ......
y ---- — _----— { nit u tnr r
+ I - W Mona pdsmJ
lU,UUU
J PERSOML&ADV INJURY a 1 00 0 000
F. EGATELMTAPPLIESPER ? 1
GEN'LAGGRGENERAL AGGREGATE 0t�
i et1L fl y : PR1L ; i F. e PRODUCTS {S Z_t U V_0 0 0
tF-- �'AGG S f AUTOMOBILE warm CfS ---- i 000 0
ANYAUTD
rt
ALLOVVNED SCHEDULED � LELaaeeida__�1 N_----- ;
AUTOS AUTOSBODILYINJURY(Pet person) 1 s
HIRED AUTOS AUT BODILY INJURY(Per �/ s
i �sa,Hdaid
UkBRELLALIAe iii
{�P -- - _
--1 L_ OCCUR i — $
'
Li EXCESS LUU3 CLAIMS-MADE f + EACH OCCURRENCE $
I
DEB RETENTIONS
I AGGREGATE
B WORKERS COMPENSATION E
+1 MA'PROPRIETORrPARTNERIEXECUTTVE Y rN 6S59UB0224N37214 3/9/19� 3/9/20,X�_!iwc srATu oTH-
1 P ndr R EaAED� Tj N!A� rou a ,r `:.&,..
bry )
EL EACHACOCENT -s 100,0
n
i I�fyes uesalbe under va
I UESC``RIPTiON OF OPERATIONS below
e ^ .ACE. a-f ciao..t.+.weeeK w 1 0 n
j I E.L.DISEASE-POLICYLNIT $ 500 000
I !
I i i
DESCRIPTION OF OPERATIONS I LOCATIONS 1 VE MEEB f A imeh j
'I'TMC1Tp'V KTi'aTT1i[± ACOR0101,AddllfotWRereutksSglWrle.rtmon
FA lei' !L
yn,nv lawv spice is required)v a„ur r7:ynA urn cHr.. ae,.. i e.reNcire.wn __i V V 11iV11 If'Vl:4�ibL�aGT yN.�1.91!A#� -
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CANCELLATION
Srevui.0 ANY LH: Hit niduvt We/A K:NED PIES BE CANCELLED BEFORE
THE EXPIRATION DATE THE
ACCORDANCE WITH THE POLICY PROVISIOTNS ICE WILL BE DELIVERED ad
AUTHORIZED RE
..>4-,tilip
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_.........____
ACORD 25{2010/OSt 01988� 10 ACORD COR Phone:
The ACORD name and IoQo are registered PORi4T10N. All rights reserved.
Fax: Ems: marks of ACORD