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Home My WebLink AboutBLDX-23-15174- Og;;y Office Use Only '�Y '. f r w► lr7 �'� 6' � '—23 -15 V el '. ru�tT 1. s �""�� Amount •: ,,z""' ci?.. Permit expires 180 days from issue date EXPRESS BUILDING PERMIT APPLICATI ' M TOWN OF YAROUTH it6 Yarmouth Building Department 1/ 52 / 1146 Route 28023 South Yarmouth, MA 02664 U.ILDING DEPAffrMENT (508) 398-2231 Ext. 1261 B y ------______—,_ CONSTRUCTION ADDRESS: 3Z k7ie•e( Cone PP. YCL 'll i ptot, ® 4, ASSESSOR'S INFORMATION: Map: ? 'r Parcel: OWNER: V l 6-+Or� ._,... .Y'1 ( (vi. , 3 2- I"� >°e ( `ye 02 (4 * iilfNAME PRESENT ADDRESS �QDTEL. # CONTRACTOR: l7V 1 kTe i tl f 51 LOw .- (S2k)&1 t(Syq A11 a* ("A C/f 26(., NAME MAILING ADDRESS / TEL.# dResidential O Commercial Est.Cost of Construction$ I Z)S'C-C1 Home Improvement Contractor Lic.# /ci ,3O f 3 Construction Supervisor Lic.# q4'l`/ Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor 0 I have Worker's Compensation Insurance Insurance Company Name: C..-////./1 Worker's Comp.Policy# 6 5.5*J,,0 19 Z 2 YN 3? 23 WORK TO BE PERFORMED Tent ri Duration (Fire Retardant Certificate attached?) Wood Stove El Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares 2 Is (14 Remove existing*(max.2 layers) Insulation I I 7 Old Kings Highway/Historic Dist. at Replacing like for like Pool fencing IJ *The debris will be disposed of at: G//�a v t '" ' 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 revocatio f my license and for prosecution under M.G.L.Ch.268,Section 1. f ) Applicant's Signature: Date: �/ S(2-1)Z) Owners Signature(or attachment) I Date: Approved By: Date: _ ' Building Official es. EMAIL ADDR Zoning District: Historical District: - Yes No Flood Plain Zone: -- Yes - No Water Resource Protection District: Within 100 ft.of Wetlands: Yes No Yes No jot_ The Commonwealth of Massachusetts ^!! Department of Industrial Accidents 1 Congress Street,Suite 100 Boston, MA 02114-2017 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Annlicant Information Please Print Legibly Name (Business/Organization/Individual): 1/6✓1 IC474 'W>ii Address: S'i I—Ow c— 13i'od1.) jPrt City/State/Zip: '//r is D 2 y Phone#: sc)cf` 2 66 270 ? Are you an employer?Cheek the appropriate box: i[ ]I am a employer with / Type of project(required): employees(full and/or part-time).* 7. New construction 2.0I am a sole proprietor or partnership and have no employees working for me in any capacity.[No workers'comp.insurance required.] 8. Remodeling 3.01 am a homeowner doing all work myself.[No workers'comp.insurance required.]t g El Demolition 4.❑1 am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition ensure that an contractors either have wow'compensation insurance or are sole 11.QElectrical repairs or additions proprietors with no employees. Plumbg 5•01 am a general contractor and I have hired the sub-contractors listed on the attached sheet 12.QRoofr a repairs or additions These sub-contractors have employees and have workers'comp.insurance.* 13.0 Roof repairs 6.0We are a corporation and its officers have exercised their right of exemption per MGL c. 14.QOther 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. 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 employee& Below is the policy and job site information. Insurance Company Name: 6 iv 4 Policy#or Self-ins.Lic.#: 6S u U z S � 2 LUG .72 22_,S_ Expiration Date: 3/�l/ e q Job Site Address: 3 Z 1t'e( CG2-e P7- Attach a copy of the workers' compensation policy declaration page(showing the policy nufnber and expiration 2 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 'ns and penalties of perjury that the information provided above is true and correct. C Signature: Date: j(S' / 2,3 Phone#:_ 76 ® 2 7Cr2 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 :it)) DATE July 17,2023 Home improvement contractor registration f� u f z 143053 S Quotation tY 1 54 Lower Brook Rd So Yarmouth MA 02664 Phone 508)760 2702 tim ea ing hobnail corn proposal for: Job name!location: Victoria Millne Same 32 Kell Cape Dr Yarmouth Ma 02664 315 380 7777 We hearby submit specificatons and" may, J7^✓P`4" Aro,1 M"Y ?s°4 „TMi "„.« ,.,. '+ "4� r':, a 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 2 new bathroom fan roof vents An debris and trash will be removed and disposed of properly 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. 535.00 per Iv+materials if needed Materials guaranteed by manufacturers.Workmanship guaranteed by Keating Construction for 10 years, We propose hereby to furnish materials and labor for the sum of: S12,600A0 Senior Citizens discount included 1f3 payment due at start of jo and remainder upon completion Acceptance of Proposal: )tp ce..., Date of acceptance: S I f ij /Z 0 3 Acceptance of Proposal: Date of acceptance: The above prices,specifications and conditions are satisfactory and are hereby accepted. Demographic Information. Full Name: Tim B Keating Owner Name: License Address Information City: Mouth Yarmouth State: A Zipcode: 02664 Country: United States License Information License No: CSSL-099351 License Type: Construction Supervisor Specialty Profession: Building Licenses Date of Last Renewal: 5/24/2022 Issue Date: 6/4/20t38 Expiration Date: 5111/2024 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 D � >-O� _ �.__t Ili { ix x covazi r ( IMIfJ _mgE ut;,, a' 88636> z li 1 t gif 0 Z w = f3 g _ 0"-P. 8 Er .i. —w 3 o cn r oo * c O it'll amatiu.. fzi II li[! S .......0)= cm! ! .�!L -i S Ih CA CD V y = ® m §-ii. . s_ 1 . . 3 i I I i 6-4821 0 1 1 ' i _ .. .t I I i mo d` CERTIFICATE OF LIABILITY INSURANCE f DATE pMiG rONYYY) e3117/23 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. I O T A•NT: IY h.=c...;:ifta:e!sadder is en ADDITIONAL INSURED,the p►oncy(las)must have ADDITIONAL INSURED provisions or be endorsed. N SUBROGATION IS WAIVED,subject to the terms and conditions of the Pow,certain Pis may require an sndorsameat. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTANmac PAUL SCHLEGEL Schlegel&Schlegel Ins Broker PHONE 508-T71-8381 a Ertl: FAX N0k 506-771-0663 34 Westin Street Yarmouth MA 02673 S: schlegeiinsurance@gmail.com WSURERIS)AFFORDING COVERAGE RAC C DisIAI>F.n*: MOUNT VERNON INSURED INSURER 8: GYM TIMOTHY KEATING DBA KEATING INSURER C CONSTRUCTION INSURER D: 54 LOWER BROOK RD SOUTH YARMOUTH,MA 02664 INSURER E: INSURER F C CERTIFICATE TIMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSN 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. MLTR ani TYPE OF INStatANEE !I I policy RUNNER POLICY EFF POLICY EXP jiAA tourvyyuma 011YYYY LIMITS X COMMERCIAL GENERAL UABIUTY EACH OCCURRENCE $ 1,000,000 T DAMAGE TO RENTED ' #.. }�as znae me} r$ ---- MED EXP(My ens person) $ 10,000 A NN 12325470 03/19/23 03/19/24 PERSONAL a ADV INJURY ; 1,000,000 GENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POL CY 1 1 jEECt r n LOG I PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY BINGED SINGLE-CatE ANY AUTO , BODILY INJURY(Per person) $ OWNED --SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) ; HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY Per accident) $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ !~ EXCESS LIAB CLAWS-MADE AGGREGATE $ DEO I I RETENTIONS $ WORKERS COMPENSATION I STATUTE I OT AND EMPLOYERS'LIASIUTY Y 1 N ETUTE ER B OfFICERlME ANY MIOR E CLN�ERRI PROPRIETOR/PARTNER/EXECUTIVE N N 1 A 6S59UB0224N37223 03/09/23 03/09/24 E.L.EACH ACCIDENT $ 100,000 (M �eny in ) E L DISEASE-EA EMPLOYEE $ 100,000 Iiyes des,(Ea under DE CSCRIPTION OF OPERATIONS below - E.L.DISEASE-POLICY LIMIT $ 500,000 II i DESCRIPTION OF OPERATIONS(LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) TIMOTHY KEATING HAS ELECTED TO BE COVERED UNDER HIS CURRENT WORKERS COMPENSATION POLICY INSURANCE COVERAGE IS UNITED 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 OV TOWN OF YARMOUTH ACCORDANCE WITH TILE POLICY PROVISIONS- BUILDING DEPARTMENT YARMOUTH MA AUTNORIZEDREPRFS4NTME I ear @ 1988 2015 ACORD CO PORATION. 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