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HomeMy WebLinkAboutBLD-23-002036 Pik- RECEIVE ® Office Use Only S. o, nRc a Permit# e.,_,I o/1 :N '�� = , OCT 17 2422 Amount 50 B 1..11 uC erA 2 1 E N T Permit expires ISO days from BY issue date 6&D- ,23 -462P36 EXPRESS BUILDING PER MIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 (508)398-2231 Ext. 1261 CONSTRUCTION ADDRESS: Z V. /'S ;,4 ' ,) "/— Lie c '1— Art-74m.fiz, ASSESSOR'S INFORMATION: IMap: I Parcel: OWNER: P dNAME�till h L1 M r S V J S',..A ' ( 51 kJf'it S 'i,--,7e-cf-P PRESENT ADDRESS L. # CONTRACTOR: I ) i"i l(r" 17' ) 5't/G.en,) (/wL ff/ 1,-4/-Kii Yfr(NAME MAILING ADDRESS TEL.# Sd ef lid Z 7r/e dResidential ❑Commercial Est.Cost of Construction$ 9 7 S U u 7 Home Improvement Contractor Lic.# f ' 3 L3.S 95 '3-S Construction Supervisor Lic.# �`7 Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 II am the sole proprietor 0 I have Worker's Compensation Insurance Insurance Company Name: C/f f'7 Worker's Comp.Policy# 4,S,S L/o g o a z v 17z Z z WORK TO BE PERFORMED Tent ii Duration (Fire Retardant Certificate attached?) Wood Stove El Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares / 6 ( )Remove existing* (� (max.2layers) Insulation I 1 1-1 Old Kings Highway/Historic Dist. CD Replacing like for like Pool fencing F *The debris will be disposed of at: Y6 r(li O i 1-4" 1 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 revocati n of my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: /a // (2 U Z Owners Signature(or attachment) Date: Approved By: r���MAIL �� 17` Building Official(or designee) E ADDRESS: Date: Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: ❑ Yes 0 No 0 Yes 0 No c,►"' -== The Commonwealth of Massachusetts _ 1= Department oflndustrialAccidents t ': I Congress ess Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. A !leant Information Name (Business/Organization/Individual): Please Print Le 'IA Address: t/ (1 C, 2 nci City/State/Zip: C�i.,// 1, Phone #: Sc1 a Are you an employer?Check the appropriate box: �� �� 1. I am a employer with • employees Type of project(required): —�--_ (full and/or 2.0I am a sole proprietor or partnership and have no employees working forme in 7. 0 New construction any capacity.[No workers'comp.insurance required.) 8. Remodeling 3.01 am a homeowner doing all work myself. [No workers'comp. insurance required.]t 9. 0 Demolition 4.0I 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 10 0 Building addition proprietors with no employees. 11.[]Electrical repairs or additions 5.0I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 12.❑Plumbing 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.OOther 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 indicatingthey :Contractors that check this box must tao are doing all work and then hire outside contractors must submit a new affidavit indicating such. employees. If the sub-contractors attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have tractors have employees,they must provide their workers'comp, I am an employer that is providing workers'compensation P policy number. information, rnpensation insurance for my employees. Below is the policy and job site Insurance Company Name: f Policy#or Self-ins.Lic.#: 22 c',t.,,.7>2Z2 Expiration Date:___- ' Z ' Job Site Address: ' 1 e _5- ��- ` City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy nu ber an Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable bya fine up to$1,500.00 d expiration date). and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of u day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIAp $2ra ce a coverage verification. for insurance I do hereby certify uncle the pains and penalties of perjury that the information provided above is true St nature: and correct Phone#: l� Date: a::%C(' -2 Z c.) 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 Ins 6.Other b pector Contact Person: Phone#: A►ccwo" �-- CERTIFICATE OF LIABILITY INSURANCE DATE�tMM►DDr illarimpTHIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES3117/2, BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),S), HOLDER.THIS REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. I PO- ANT: If the certificate holder is an ADDITIONAL INSURED,the ( ).AUTHORIZED If SUBROGATION WAIVED,subject o the terms and conditions INSURED the Pal certain must have es may require INSURED r ment or e statement or this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). policy, policies may an endorsement A of PRODUCER Schlegel&Schlegel Ins Broker :T JIM HINDMAN 34 Main Street , : 508-771-$381 West Yarmouth,MA 02673 r+„ • Ar1c No: 50$-771-066 ADOREss: schlegellnsuran :�: .mall.com INSURER S AFFORDING COVERAGE INSURED INSURER A: MOUNT VERNON NA TIMOTHY KEATING DBA KEATING INSURER e: CNA CONSTRUCTION INSURER C 54 LOWER BROOK RD INSURER 0 SOUTH YARMOUTH,MA 02664 INSURER E COVERAGES CERTIFICATE NUMBER: INSURER F THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD REVISION NUMBER: 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. LTR TYPE E OF INSURANCE +••NH-MT-MO' + © COMMERCIAL - POLICY NUMBER MM/D.• �•GENERAL LIABILI Y .. LIMITS �■ CLAIMS-MADE C OCCUR EACH OCCURRENCE S 1,0 ...... 3 5 A NN 12325470 MED EXP An one.arson . S 03/19/22 03h9/23 PERSONAL&ADV INJURY $ 1,0 GEN'L AGGREGATE LIMIT APPLIES PER: 1111 POLICY PER4 LOC INEM $ 2,0 IIIOTHER PRODUCTS-COMP,OP AGG $ 2,0 AUTOMOBILE LIABILITY $ III ANY AUTCOMBINED 8 SINGLE LIMIT $ BODILY INJURY OWNED SCHEDULED (Per Person) $ S AUTOS ONLY AUTOSin 1 MINI HIRED NON-OWNED BODILY INJURY(Per accident) PROPE- DAMAGE $ IIIAUTOS ONLY AUTOS ONLY Per accident $ IIIUMBRELLA LIAR OCCUR S 1111 EXCESS LIAa CLAIMS-MADE EACH OCCURRENCE $ r $ DEO RETENTION S IgrnIIIIIIIIIII $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY S ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N STATUTE HRH B OFFICER/OEMBER EXCLUDED? N/A 6S59UB0224N37222 E.L.EACH ACCIDENT (Mandatory In NH) I+yyeess describe under 03/091Z2 03l09/Z3 S 11 DESCRIPTION OF OPERATIONS below E,L.DISEASE-EA EMPLOYE z S 11 E.L.DISEASE-POLICY LIMIT S 51 )ESCRIPTION OF OPERATIONS/LOCATIONS t VEHICLES (*CORD 101,Addttional 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 LIMITED TO THE TERMS,CONDITIONS,EXCLUSIONS AND OTHER LIMITATIONS AND ENDORSEMENTS OF THE POLICY :ERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEF THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN TOWN OF YARMOUTH ACCORDANCE WITH THE POLICY PROVISIONS. BUILDING DEPARTMENT YARMOUTH MAAi AUTHORIZED REPRESENT © ' .;-2015 ACnOn r•nnn.,n ... -<p0 ws DO 's�'m= x= 0 • -I? w m =x1X G2,�� SO p m co 153 co y"z O0 _,' m ;c Hli z E. s doz ` Y Z�II-4 "nm3 049g5a N —�N rn X --. 3 to T C r'' .i : > Oyu ro L Om v 73 ai 0 CD 2 a m -` 0 3 n z n 3 o o cnn m D * c O m � m Z o >>>m' 2 :- Co � I <DI :33 . _0 a, vcD0a , Et 02-DCo o � D f 2 ,8.s` xi - p c y Cn a O emWc CD D CCD D co .., n Warm c � m -a cn- CbjCn I co co x C DI c I __ ca m CD 21 if al CI) co to Q a W 0< �-► c -. n'Wa 0 C m I 0 N t/1 � 'P. >, 2+ j.�., N N d J df � O VNI Q G ^. QQ0 cc in o c tZ- O c O 2 °� E.2 7 ' z E�°° Fm� Up O C r- WWges} 0 a Q m V N O m J� ►=.0(0 E co 0 V , ! 'T 0 • • 0 • ci 'r.-.1 q fzin r § g ,....., ,..,e , 1 .., . , got t [ry, ,014, I,ra a j,el RI (An I< I ip . p -. (,) 15 w g. . or- CD 0 01 1 i r2 (I) g -4, 11, 4,—#0,it E li..:3 '4‹ 000 0 1-.LI ati utp C", ,r0 iti ,c) icta w . ...... A a „.,.....: ,.... fr:- fo5 e , i. err , klIg 0- go. = a i 07 1 1 ..„„* 1 1 I . .... ki. a I 6 IR 8 iv 1 11 0)..,,, I 44i i . a R 3 to , f 20 911 4 ga 0 * 1 "2 (fig P i •4°,14. 0 .1"to CD RI 4.e <1 <1 <I a 1<rkii2.4 1"4".., of* g 3 1 o) ecf 4 SA C-- * •4 0. g ,..4. a iii_ g I 28, iaz po.: ,1 if 2 S 5 1 5' 0 ar I ,ic f§ 'at CD to 3 44( ti N. CP 0 0 0 0 co 0, 0, I 1 a z R. . g .... > law 3 ...a Keating Construction I* Home improvement contractor registration: 143053 DATE August 22, 2022 54 Lower Brook Rd Quotation# 1 So. Yarmouth MA 02664 Phone(508)760 2702 timKeatinb66(c hotmaii corn Proposal for: Donna Thompson Job name/location: 2 Virginia St Same West Yarmouth Ma We hearby submit specificatons and Strip roof shingles off entire house Install water and ice shield on lower edges and chimneys Install new vent pipe flanges and 30 lb tar paper on decking Install new whit 8 inch drip edge Install Certainteed Landmark 30 yr architectural shingles .-- 1, 5LC ck Install ridge vent at all peaks Remove all rake boards Install Azek trim boards on all rakes All 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. $35.00 per hr+ 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: $9,750.00 Senior Citizens discount included 1/3 payment due at start of job and remainder upon completion Acceptance of Proposal: ...--Date of acceptance: L t7 I 4(2:2--- • Acceptance of Proposal: Date of acceptance: The above prices, specifications and conditions are satisfactory and are hereby accepted.