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HomeMy WebLinkAboutBLD-23-06164 :Y9R RECEIVED otTSceUse Only I : [ A723 Permit expires 180 days BUILDING DEPARTMENT xPfrom By issue date 3- !fi)(I /gL EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 7 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: • J Or:✓1-'1 f /---,e.cc 6 ' „e(t` y�,',� f„4 Y i 4 e 24(j ASSESSOR'S INFORMATION: Map: Parcel: OWNER: il o 1 OP C tr/ 1� /U 7 /J r,✓,',f -c C, c�� y(�a.?<i 9 / /44 NAME PRESENT ADDRESS TEL. # CONTRACTOR: kP<AL-1 L 01,0 &t1" 1�` Y4fll4u'Ie t 4/4 NAME MAILING ADDRESS TEL.# ,St),1- )(, G .esidential OCommercial Est.Cost of Construction$ Home Improvement Contractor Lie.# I 6/30->. Construction Supervisor Lic.# % '-c Workman's Compensation Insurance: (check one) El I am the homeowner O I am theht sole proprietor Er I have Worker's Compensation Insurance Insurance Company Name: i(� 4 Worker's Comp.Policy# ,S ) `1,L 3 7 22-3 WORK TO BE PERFORMED Tent LI Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares Z ( Remove existing*(max.2 layers) Insulation ! 1 Old Kings Highway/Historic Dist. 0)Replacing like for like Pool fencing n *The debris will be disposed of at: `lGl w►!>✓ , 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 rev ation of my license and for prosecution under M.G.L.Ch.268,Section 1. / l Applicant's Signature: Date: ..5 )/ 23 Owners Si ature(or attachment) :::.: Building Official(or d gn EMAIL ADDRESS: Zoning District: Historical District: :a Yes No Flood Plain Zone: Yes No Water Resource Protection District: Within 100 ft.of Wetlands: Yes No Yes No The Commonwealth of Massachusetts I' f Deparirneni ofkulustrialAccidents i, lel_ 1 Congress Street,Suite 100 Boston, MA 02114—B017 �,X=;r• www.muss.govldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH.TUE P : TING AUTHORITY. Applicant Information Please Print Legibly Name usiness/O(B rganizatior>llndividual): E r/4/ h—f S7`;;--►5 Address: �'t( -derv; °sr �w f?L City/State/Zip: '1 orrrll inA 016 5 Phone#: S-6 & -WO 2) z Are you an employer?Cheek the appropriate box: Type of project(required): .11:1l am a employer with ( employees(full and/or part-timer 7. New construction 2.0I am a sole proprietor or partnership and have no employees working for me in 8. El Remodeling any capacity.[No workers'comp.insurance required.] 3.01 am a homeowner doing all work myself[No workers'comp.insurance required.]t 9. ❑Demolition 10❑Building addition 4.1:1I 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 11.0Electrical repairs or additions proprietors with no employees. 12.QPlumbing repairs or additions 5.0I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 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,§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. 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. lithe 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: C Policy#or Self-ins.Lic.#: 6.5 S�i v g 12_4,, 7 L Z 3 Expiration Date: 3/ Job Site Address: is ) l�r t�,'�r //f( City/State/Zip: ' ./9 62 y. 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 wide the pains and ponnitiPc of that the information provided above is true and correct Signature: Date: 510/2 ? Phone#: 5 a Sr- T rS Z 7 6 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 Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: Keating Construction Home improvement contractor registration: DATE April 5, 2023 143053 Quotation# 1 54 Lower Brook Rd So.Yarmouth MA 02664 Phone(508)760 2702 t,mkeating66ahetmail.corn Proposal for: Job name/location: John Occhino Same 107 Driving Tree Circle Yarmouth Ma 02664 We hearby submit specificatons and Strip roof shingles off entire house and install new 8 inch drip edge Install water and ice shield on lower edges and chimneys Llr n9 � Install new vent pipe flanges and 30 lb tar paper on decking c 9 f e-' Install Certainteed Landmark 30 yr architectural shingles Install ridge vent at all peaks Remove rake boards and install Azek Trim Boards Remove front wall siding and install clear cedar and step flashing Install 2 gable vents supplied by homewner n c& 1 cr n V n rs Fa R R ° #140.ni n s c u r h S G f e�?ry S`) All debris and trash will be removed and disposed of properly Only items specified above are included in this Proposal. Chimney flashing replacement is net included it this rwoposEd 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. 1 Senior Citizens discount included 1/3 payment due at start of job and remainder upon completion Acceptance of Proposal: r.. Date of acceptance: (5 ( 2 v Z 7 Acceptance of Proposal: • Date of acceptance: 44 / !S�f ) )- The above prices,specifications and conditions are satisfactory and are hereby accepted. t A v, CERTIFICATE OF LIABILITY INSURANCE DATE`11 " 1e.,...-' 031Z3/23 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 policy(ies)must have ADDITIONAL INSURED 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). PRODUCER NAM: PAUL SCHLEGEL PROM Schlegel&Schlegel Ins Broker E•MAr9,E,ttl; 508-771-8381 FA/AXC,Pie): 508-771-0663 34 Main Street ADDRESS, schlegelinsurance@gmail.com West Yarmouth,MA 02673 INSURERS)AFFORDING COVERAGE NAM I INSURER A: MOUNT VERNON INSURED INSURER B: CNA TIMOTHY KEATING DBA KEATING INSURER C: CONSTRUCTION INSURER D: 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. TYPE OF INSURANCE ADULSUBR POLICY NUMBER POLICY EFF POLICYEXP INSR_ INSD WVD (MM/DDIYYYY) IMMIDD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 DAMAGE TO RENTED CLAIMS-MADE I XI OCCUR PREMISES(Ea occurrence) $ 500,000 MED EXP(Any one persona S 10,000 A NN 12325470 03/19/23 03/19/24 'PERSONAL ti AMINJURY S 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000 POLICY n JPER&& ` i LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: ... $ AUTOMOBILE UABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS �— HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ V EXCESS LIAR CLAIMS-MADE AGGREGATE S DED RETENTION$ S WORKERS COMPENSATION PER AND EMPLOYERS'LIABILITY STATUTEH YfN ER B AFFICERMEMBER EXCLUDEDXECUTIVE1;-- N/A 6S59UB0224N37223 03/09/23 03/09/24 E L.EACH ACCIDENT $ 100,000 (Mandatory In NH) I ^ E.L.DISEASE-EA EMPLOYEE S 100.000 If Ii under DESCRIPTION OF OPERATIONS below E.L.DISEASE•POLICY LIMIT 15 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If men space Is required) TIMOTHY KEATING HAS ELECTED TO BE COVERED UNDER IllS 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 POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE P• ICY• -OVISIONS. josh_coffey2000@yah0o.com, AUT' •RUED REPR N / . 1 _ ji ®1988-2015 ACORD CORPORATION. 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