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Home My WebLink AboutBLD-23-002803 p? Y. tin� 1// z1/ZZ, Office use only C .aI('\! y Permit# 11111 ��LAmount �0.40 Peamit expires 180 days from issue date EXPRESS BUILDING PERMIT APPLICATION-2 3 PPLICAT ON—a3 -Odol TOWN OF YARMOUTH Yarmouth Building Department RECEIVED 1146 Route 28 -a— - - i South Yarmouth,MA 02664 NOV 21 2022 (508)398-2231 Ext. 1261 CONSTRUCTION ADDRESS: VI I l 6..1 if-S t ti ar,, (Az V 6 2 6 6 ,BYU I LD I NG DEPARTMENT ________________ ASSESSOR'S INFORMATION: IMap: I Parcel: I OWNER: U 1 ce OGrS:/ 2 /1/,,tltc z•-, y/ 0-1/1 _1 ADDRESS TEL. # CONTRACTOR: IJ t c M �(�-e4 lii nI 5`�/ LUwec gi,v4.,.Pf )q1'� v1A14( ME MAILING ADDRESS TEL.#. �BResidential `��2 �v� D Commercial Est.Cost of Construction$ 7/Sad Z" Home Improvement Contractor Lic.# /i3//C3 Construction Supervisor Lie.# D Gt q 3 C7 Workman's Compensation Insurance: (check one) 0 I am the homeowner Cl I am the sole proprietor WI have Worker's Co G /v r l � Compensation Insurance Insurance Com pany Name: Worker's Comp.Policy#C-,51 ✓l3G31 a yyz 2??Z. WORK TO BE PERFORMED Tent .0 Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares (Remove existing* 17 (max.2lsyers) Insulation Old Kings Highway/Historic That. (D Replacing like for like I 1 Pool fencing "The debris will be disposed of at: Wit.N?0.11- ! /0 Location of Facility I declare under penalties of perjury that the statements herein contained are true and correct to the best of my knowledge will be just cause for denial or ocation of my license and for prosecution under M.G.L.Ch.268,Section 1. and belief. I understand that any false answer(s) Applicant's Signature: 1 Date: Cl/2/f 2UL7, Owners Signature(or attachment) '" Date: Approved By; Date: //c/��19 -. Building Offic' or ) EMAIL AD S: Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No for CERTIFICATE OF LIABILITY INSURANCE DATE NIIINOCV THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION d3M7/2 THIS ATE DOES NOT Efl ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER,THIS BELOW. THISAFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED CERTIFICATE OF S4SURANCE DOES NOT CONST TU E A CONTRACT BETWEEN THE ISSUING INSUUER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. 1 : If the holder Is an L INSU ,the if SUBROGATION IS WAIVED,subject to the terms and conditions of the )must have or ae this certlllcate does not confer to the certificate holder in lieu of suchp crsem ) fis policies may require an endorsement. A or PRODUCER . Schlegel&Schlegel Ins Broker JIM HINDMAN 34 Main Street . 508.7714381 West Yarmouth,MA 02673 sch se: 508471.064 Isom s AFFORD/COVERAGE NA INSURED RO MlER A: MOUNT VERNON INSTIMOTHY KEATING DBA KEATING INS e: CNA CONSTRUCTION INSURER c 54 LOWER BROOK RD INSURER D: SOUTH YARMOUTH,MA 02664 INSURER E COVERAGES CERTIFICATE NUMBER: INSURER F THIS IS TO CERTIFY THAT THE Pt?LICMS OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSUREDREVISION NUMBER: INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONOmON OF ANY CONTRACT OR OTHER NAMED ABOVE ES CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE POLICY PERIOD EXCLUSIONS AND CONDITIONS OF SUCH POUCIESS..LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. SUBJECTD BY THE POLICIES DESCRIBED HEREIN IS TO ALL THE TERMSCT TO WHICH , L TYPE of INSURANCE X COMMERCIAL IERM.tiABIJrr POLICY NUMBER WAITS CLAIMS-MADE Q OCCUR EACH OCCURRENCE s 1,0 $ 5 A NN 12325470 Mm ' one $ GERM AGGREGATE LIMIT APPLIES PER: 03/19/22 03/19/23 PERSONA LS ADV I._._Y i 1,0 POLICY ACT LOC GENERAL.AGGREGATE S 2,0 OTHER: PRODUCTS-COMP/OP AGG 2d, AUTOMOBILE LIABILITY s — ANY AUTO I� AUTOS ONLY SCHEDULED D BODILY INJURY(per P nl s AUTOS ONLY S HIRED NON-OWNED (PBODILY INJURY(par 1 $ ._ AUTOS ONLY er_itzsi s nl] s UMBRELLA UAO OCCUR $ EXCESS LIAR CWMS MADE EACH OCCURRENCE DED RETENTION s AGGREGATE $$ WORKERS Tyr ER AND EMPLOYERS'LIABILITY ANY PROPRIETORAPARTNEFVEcECUT►VE Y t N B (Mandatory In NH) R EXCLUDED? NN N A A 6356UB0224N37222 03/09/Z2 03/09/23 E.L.EACH A____ s 11 DeSeCAPTIONssa"OF t3PER/►TIONa below E.L.DISEASE-EA EMPLOYE Ea a 11 E.L.DISEASE-POLICY LIMIT s 51 MSGRIPT/ON OF OPER/Rp7NS/t oCATIONS/VEHICLES (AGGRO 101,Additional Ranted%Schodulk ttfiliN TIMOTHY KEATING HAS ELECTED TO BE COVERED UNDER HIS CURRENT WORKERS be attached a PE SA Is rN POLICY COMPENSATION POLICY INSURANCE COVERAGE IS LIMITED TO THE TERMS,CtN1IDIT10N$,EXCLUSIONS AND OTHER LIMITATIONS AND ENDORSEMENTS OF THE POLICY ERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEF TOWN OF YARMOUTH THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. BUILDING DEPARTMENT • YARMOUTNI MA AUTHORIZED*EPRESMa1T 0 -2015 ACORD core PMDWTI/mu' .II . S The Commonwealth of Massachusetts '". 1 ► / Department of Industrial Accidents ?dNl_ 1 Congress Street,Suite 100 r41 Boston, MA 02114-2017 yr r`t www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Auulicant Information Please Print Legibly Name (Business/Organization/Individual): �►-i �� >S Address: . L r1 w e c et 4. P City/State/Zip: /Glut„) M' i9&ti Phone#: ...5 a k 7 66 Z ci Z 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. ❑New construction 2.01 am a sole proprietor or partnership and have no employees working for me in 8. Q Remodeling any capacity.[No workers'comp.insurance required.] 3.0I am a homeowner doing all work myself[No workers'comp.insurance required.]t 9. Demolition 4.0I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 El Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.QElectrical repairs or additions proprietors with no employees. 12.['Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contactors listed on the attached sheet 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.' 6.0We 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 ch ke 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 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: (,4,/,4 Policy#or Self-ins.Lic.#: 65 5 c v 6 d Z?i v 3 2 22 Z Expiration Date: S 5� 'z Job Site Address: 21/ City/State/Zip: cf' 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 the pains and penalties of perjury that the information provided above is true and correct Signature: ir-et9,4 Date: l//a,v ? 1.-? Phone#: S Cr —76 0 2 -7® 7 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 CIerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: r o co 3 NrZiitio 6/ ZU) 0W coh m p X to O a a.a U) o < O Al 1 to -itcr W CA' 3 r� `� Nay rr' ' )ref:ki` o a m 1 c � � "m 0 `` near or - N t . A I p `7.ccO J_ A 3 `i.„ 451• rillSgEg IRlici_Wli k. E• 0} to O'CC re f U'go ' < ,. .0W )Z Ymb F- izA� 1 I c• c I o 3 § Mi 1 0 I 2% a :i� ..1...s.. ' a at cc 0 1 $mi a r _ r I 7,... = is ... ,:, Iiel 37 Cr. To 3. O c � s z° i=- o` Iliii '�; Z a, to _ O = vv,, c. co C m o r w o = E2 ' 'd i ., guig p ._ • it gi , . .. .. ... tali, i, - 30gi 11'7: F, F-[] v, W'S i Ydd LGm CZ 2 3 =w XW Y Mai M-,� I3emographir Information Full Name: Tim B Keating Owner Name: License Address Information City: South Yarmouth State: MA Zipcode: 02664 Country: United States License information License No: CSSL-099351 License Type: Construction Supervisor Specialty Profession: Buildin• Licenses Date of Last Renewal: 5/24/2022 Issue Date: 6/4/2 r . Expiration Date: 5/11/2024 License Status: Active Today's Date: 7/25/2022 Secondary License Type: Doing Business As: Status Change Reason: License Renewal Prerequisite Information Licensee: Keating, Tim B Relationship: Attribute Of License No: CSSL-099351 Licensee: Keating, Tim B Relationship: Attribute Of License No: CSSL-099351 No Available Documents a : . Home improrement contractor registrabon: DATE November 4.2022 143063 Quotation#1 54 Lower Brook Rd So.Yarmouth MA 02884 Phone(508)760 2702 k ' larvosel for: Job name/location: Janice Dasilva Same 24 Niagara Lti Yerrnotab Ma 02$37 399 944 8974 We hearby submit speccatons sod Strip root shingles off entire house install water and ice skald on lower edges and chimneys Install new vent pipe Unties anti 30th tar paper on decking triate9 whZe 8 inch drip edge on all eves Malta Cortainterid Landmark 30 yr architectural shingles instal ridge vent at all peaks Ail debris and trash wit be removed and disposed of ixoperly only items epecifiad above are trichried in this proposal Chimney nestling replacerrient is not mcitkled in this proposal Rotted wood rapt**is not included In this proposal, $35,00 per is+matedatet if needed Materiels guaranteed by manufacturers.Vtiorionanship guaranteed by Keating Ocirternicitori for 10 years. We propose hereby to furnish materiels and labor for the,sum of $7300.00 Senior Citizens discount included 1,3 payment due at start of job and rerriairtder.cmon completion • /-1 Acceptance of Proposal:.....441:12fez: Date of acceptance:.22/221.&.2„...1._ Acceptant*of Proposal: Date of acceptance: The above prices.SpedfiCati0118antl conditions are satisfactory and are hereby accepted • S