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Home My WebLink AboutBLDX-23-15065 � 6,4 lf `t' 2,,VyZ3/2) s�t;ye - ermit# 0 H. e-i ce+in d$ Amount c- Permit expires 180 days from issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH IRECEiVED Yarmouth Building Department 1146 Route 28 JUL 2 4 South Yarmouth, MA 02664 2023 (508) 398-2231 Ext. 1261QtPAR r - � CONSTRUCTION ADDRESS: �Js 0 trGtn e 4ve 1.1�rin U - By �— 'FAASSESSOR'S INFORMATION: Map: n Parcel: �j�/) OWNER: Y' t l K f Z t, ,i ° /sr-S. 4//41e Av/ y61 /i41 f4 NAME PRESENT ADDRESS TEL. # CONTRACTOR: T —17fi is Si Lotc.,r, (Srjv P� �l tive.4)-i- kw' NAME MAILING ADDRESS TEL.#SOS 76-6 e'7 d 2 Residential ❑Commercial Est.Cost of Construction$ (2f$'L� Home Improvement Contractor Lic.# / Lf 30 S3 Construction Supervisor Lie.# 94 35 l Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor II I have Worker's Compensation Insurance Insurance Company Name: (N 4 Worker's Comp.Policy# C S 6-9 0273-1✓ ' 71 WORK TO BE PERFORMED Tent El Duration (Fire Retardant Certificate attached?) Wood Stove El Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares 2 ' (d)Remove existing*(max.2 layers) Insulation 11 I 1 Old Kings Highway/Historic Dist. d Replacing like for like Pool fencing I I *The debris will be disposed of at: ctirm oj,,YA 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 revoc ' n of my license and for prosecution under M.G.L.Ch.268,Section 1. ) Applicant's Signature: Date: 7 Z II 2.3 Owners Signature(or attachment) Date: Approved By: /72S— Date: "—. 2 i Building Official esi EMAIL ADDRESS: Zoning District: Historical District: -. Yes No Flood Plain Zone: -1 Yes No Water Resource Protection District: Within 100 ft.of Wetlands: : Yes No Yes No -hp/ kekhil 6(�° Affan f/. Corn 'Accisz DATE d CERTIFICATE OF LIABILITY INSURANCE ` ) tgfl7t23 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policyfles)must have Aoornomat.mimeo provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCERwCT PAUL SCHLEGEL Schlegel&Schlegel Ins Broker m pa etc; 50 -771- 1 taC,No): 508471.0683 34 Main Street ram:: echlegelinsurance@gnaILcom West Yarmouth,MA 02673 INSUREMOMAFF RD=COVERAGE tux INSURER A: MOUNT VERNON INSURED INSURER B: CNA TIMOTHY KEATING DBA KEATING INSURER c: CONSTRUCTION INSURER 0: 54 LOWER BROOK RD - SOUTH YARMOUTH.MA 02664 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED_ NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. MLIR ISR ItiatlasUlett TYPE OF INSURANCE O POLICY NUMBER _IMM/ O/YYI'Y} odspro /YYYY), UNITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 DAMAGE'TO RENTED CLAIMS-MADE I#Cl OCCUR PREMISES Ea sem nrence) f 500,000 MED EXP(Any one person) S 10,000 A — NN 12325470 03/19/23 03/19124 PERSONAL 5 ADV INJURY S 1,000,000 — GENT.AGGREGATE LIMIT APPLIES PER' GENERAL AGGREGATE S 2,000,000 -1 POUCY n JIE&T n LOC PRODUCTS-COMP/OP AGG S 2,000,000 OTHER: E AUTOMOBILE LIABILITY (EsCOM BacddeOntj INGLEI�IT S 9ANY AUTO BODILY INJURY(Per person) S OWNED --SCHEDULED BODILY INJURY(Per accident) S AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE S AUTOS ONLY _ AUTOS ONLY (Per accident) 5 UMBRELLA UAB OCCUR EACH OCCURRENCE S EXCESS LIAR CLAIMS-MADE AGGREGATE .$ DEO 1 RETENTION S i , S WORKERS COMPENSATION AND EMPLOYERS'LIABILITY Y NI STATUTE ER B ANY OFFICER/MEMB R EXCLUDED?ECUTIVE N N I A �UB0224N37223 03/09123 03/09/24 EL.EACH ACCIDENT S 100,000 (Mend eery in Ni4) E L DISEASE-EA EMPLOYEE $ 100,000 II yysess describe under DESCRIPTION QF OPERATIONS below E.L DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORO 101,Additional Remarks Schedule,maybe attached N mere space is required) TIMOTHY KEATING HAS ELECTED TO BE COVERED UNDER HIS CURRENT WORKERS COMPENSATION POLICY INSURANCE COVERAGE IS LIMITED TO THE TERMS,CONDITIONS,EXCLUSIONS AND OTHER LIMITATIONS AND ENDORSEMENTS OF THE POLICY CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN TOWN OF YARMOUTH ACCORDANCE WITH THE POLICY PROVISIONS. BUILDING DEPARTMENT YARMOUTH MA AUTHORIZED REPRESENTATIVE ts 01988-2015 ACORD CO ORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department oflndustrialAccidents 1 Congress Street, Suite 100 — Boston,Boston, MA 02114-2017 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): 17'"i k e9 4 I-i'.4 5 Address: .S i L- Ocoee- Ere() Fit City/State/Zip: yll/ &OA M 6 26 Phone#: Sdig" 760 Z7cf Are you an employer?Check the appropriate box: Type of project(required): 1.01 am a employer with > 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. VgRemodeling any capacity.[No workers'comp.insurance required.] 3. I am a homeowner doingall work t 9. ❑Demolition ❑ myself.[No workers'comp.insurance required.] 4.0I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Q Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.El Electrical repairs or additions proprietors with no employees. 12.QPlumbing repairs or additions 5.pI am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance? 6.[JWe are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q 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 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: CA/A Policy#or Self-ins.Lie.#: 6S 5 5 J C42z(4.4) 3 70 23 Expiration Date: 3/rZ/Z* Job Site Address: / P c4e Ave City/State/Zip: 2/CAoliekfilAttach a copy of the workers' compensation oli declaration a e showin the olic n p cY p g ( g p y 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 a pains and penalties of perjury that the information provided above is true and correct. Si azure: Date: 23 23 Phone#: S oe!i- 7o d Z 2 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#: Keating Construction ikje Home improvement contractor registration: 143053 DATE July 17, 2023 54 Lower Brook Rd Quotation# 1 So. Yarmouth MA 02664 Phone (508)760 2702 timkeatinQ66(u7hotmaii corn Proposal for: Mike Zwirko Job name/location: 185 Diane Ave Same Yarmouth Ma 02664 413 262 8885 We Nearby submit specificatons and Strip roof shingles off entire house Install Certainteed water and ice shield on lower edges,valleys and chimneys Install new vent pipe flanges and 30 lb tar paper on decking Install new white 8 inch drip edge Install Certainteed Landmark 30 year shingles Install ridge vent on peak Install 3 bathroom fan roof vents %II debris and trash will be removed and disposed of properly iy items specified above are included in this proposal. mney flashing replacement is not included in this proposal ed wood repair is not included in this proposal. $35.00 per hr+materials if needed rials guaranteed by manufacturers. Workmanship guaranteed by Keating Construction for 10 years. to 113 dent due at start of job •nd remainder upon completion Accept Ace of Proposal: ► Date of acceptance: (2 cepta-e of Proposal: �'i§ 1 acceptance: Date of a T he ave ices, specifications "d conditions are satisfactoryand are hereby accepted. Demographic Information Fy11 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 f'i. 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-092351 Licensee: K Tim B License No: CSSL-099351 No Available Documents , cl u) � b 1 at Wm i N cc 0 If I ti ��,. 0. JIJJ 8�� a O m g §Rat r c z co .c(§ Ili fifti 4 - JI op 2 Et° 5o 0 c oE 2 o w oEigIT 8 oto o D III p COO' a , •(4 x2 "' �ry s u�?�� i F i8-6.1m H0-lo Wt WZ Y V'5 .9, Q.>"