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HomeMy WebLinkAboutBLDX-23-15626- OTc''YAR • Office Use Only Ou . 0-3Amount C MATTACM ESE .Po�R[0M ca.' Permit expires 180 days from "issue date EXPRESS BUILDING PERMIT APPLICAT iO - Ls TOWN OF YARMOUTH Yarmouth Building Department NOV 3 2023 1146 Route 28 ,,,.,Ls' __ South Yarmouth MA 02664 B ` ` �'�R '�' (508) 398-2231 Ext. 1261 • CONSTRUCTION ADDRESS: !o ( ( G•p € i tA CA6f.e P it /4�JCi LASSESSOR'S INFORMATION: yeir/v, Map: Parcel: OWNER: �p�,�.,, NAME P SENT ADDRESS TEL. # "�/ NAME ��Q�, �^� TEL. CONTRACTOR: s MAILING ADDRESS � L # ❑Residential ❑Commercial Est.Cost of Construction$ /6 j S k) Home Improvement Contractor Lic.# 1 CI 3 o$3 Construction Supervisor Lic.# 7 35 / Workman's Compensation Insurance: (check one) ❑ I am the homeowner 7 I am the sole proprietor ❑ I have Worker's Compensation Insurance Insurance Company Name: C:/ y# �S S 4 v U 2e Q Worker's Comp.Polic 4 17 22 j WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares a t ( )R, to ve existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: y47 C1 ® z 6 6. / 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 revocation of my license and for prosecution under M.G.L.Ch.268,Section 1. L---X Applicant's Signature: it Date: 111 1-1/ 23 Owners Signature(or attachment) /��' Date: Approved By: Date: /f j i A, Building icral designee) EMAIL RESS: Zoning District: Historical District: ❑ Yes P No Flood Plain Zone: D. Yes ❑ No Water Resource Protection District: Within 100 ft. of Wetlands: ❑ Yes 111 No P Yes C No The Commonwealth of Massachusetts • Department of Industrial Accidents 1 Congress Street, Suite 100 <' f Boston, MA 02114-2017 M„_• 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): ( 1'1 k' c Address: S c-i erctcd City/State/Zip: y4,r-/I/v, ' Phone #: mod ' )60 2, )02 Are you an employer?Check the appropriate box: Type of project(required): 1.1/ I am a employer with I employees(full and/or part-time).* 7. New construction 2. I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers'comp. insurance required.] 8. ,( Remodeling 3. I am a homeowner doing all work myself. 9. — Demolition y [No workers'comp. insurance required.]t 4.E I am a homeowner and will be hiring contractors to conduct all work on mY property. I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.E Electrical repairs or additions proprietors with no employees. 12.—Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp. insurance.$ 13.]Roof repairs 6.❑We 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 checks box 41 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: C// � /(,— Policy#or Self-ins. Lic. #: 6 S'o :OD?2u .v3 ? ZZ1 Expiration Date: 3 l /'/ '2'fr Job Site Address: 0 6- e-t%1 C� J � City/State/Zip: Yrefr7C4....:71/4_/ C'266 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 under the p and penalties of perjury that the information provided above is true and correct. S ionature: Date: ( 2_1 27 Phone#: ,SU , -- '76.1 2 - 22 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. EIectrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: Keating Construction elip Home improvement contractor registration: DATE July 27, 2023 143053 Quotation# 1 54 Lower Brook Rd So. Yarmouth MA 02664 Phone (508)760 2702 timkeating66na.hotmail.com Proposal for: Job name/location: Cathy McCarthy Same 104 Captain Chase Rd Yarmouth Ma 02664 774 266 3853 We heart);submit specificatop.s and Strip roof shingles off entire house Install Certainteed water and ice shield on lower edges and chimneys Install new vent pipe flanges and 30 lb tar paper on decking it staii new white 6 ineti drip edge Install Certainteed Landmark 3n year shinnies Install ridge vent on all peaks All debris and trash will be removed and disposed of properly Only items specified above are included in this proposal. Chimney Clashing 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: $10,500.00 Senior citizens discount incluA d w4.v 1/3 payment due at start of job and remainder upon completion / Acceptance of Proposal: (_J�% '2 - Date of acceptance: J' S 1 2 Acceptance of Proposal: Date of acceptance: The above prices, specifications and conditions are satisfactory and are hereby accepted AC7E CERTIFICATE OF LIABILITY INSURANCE I I3rt7iz3 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 'soda, PAUL SCHLEGoEI. Schlegel&Schlegel Ins Broker A/C`Nq Ext): 508-771-8381 1{a,No): 508-771-0663 34 Main Street E-MAIL schlegelinsurance@gma0.com West Yarmouth,MA 02673 __. INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: MOUNT VERNON INSURED INSURER B: CNA TIMOTHY KEATING DBA KEATING INSURER C: CONSTRUCTION 54 LOWER BROOK RD j INSURER 0 SOUTH YARMOUTH,MA 02664 j INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 'HIS 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. INSR ADULSUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE 1NSD WVD POLICY NUMBER (MM/DD/YYYY1._JMMIDDIYYYY) LIMITS X'COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 i CLAIMS-MADE X OCCUR • DAMAGETORFNIED PREMISES+be occurrence) $ 500,000 MED EXP(Any one person) 1$ 10,000 A j NN 12325470 03/19123 03/19/24 1 PERSONAL s ADV INJURY $ 1,000,000 GEM_AGGREGATE LIMIT APPLIES PER I GENERAL AGGREGATE II$ 2,000,000 PRO- 'T- LOC I PRODUCTS-COMP/OP AGG f$ 2,000,000 OTHER: I !$ AUTOMOBILE LIABILITY I COMBINED SINGLE LIMIT ?$ ANY AUTO tEa accident] l BODILY INJURY(Per person) 1$ • OWNED SCHEDULED AUTOS ONLY AUTOS 1 BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE_____ AUTOS ONLY AUTOS ONLY (Per accident) $ ' I $ UMBRELLA LWB OCCUR EACH OCCURRENCE $ EXCESS LIAB I CLAIMS-MADE AGGREGATE $ r-- DED RETENTION$ J $ WORKERS COMPENSATION 1 I PER I 10TH AND EMPLOYERS'LIABILITY YIN ttt 114 ANY OFFICER/MEMBER EXPROPRIETORTACLUDED XECUTNE N N/A I E-L.EACH ACCIDENT $ 100,000 (Mmdwtery in NH) 6S59U60224N37223 03/09/23 j 03/09/24 ! l a yes.'describe;order I E L DISEASE-EA EMPLOYEES 100,000 DESCRIPTION OF OPERATIONS below E L DISEASE•POLICY LIMIT $ 500,000 1 1 I DESCRIPTION OF OPERATIONS I 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 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 TOWN OF YARMOUTH ACCORDANCE WITH THE POLICY PROVISIONS. BUILDING DEPARTMENT YARMOUTH MA AUTHORIZED REPRESENTATIVE 1 • ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD • Select the licensee name below for more information. (if your search produced more than one page,you may select page numbers at the bottom of this screen.) • Select the Search for a Person or Search for a Facltlty button to perform a new search. • Select the Preview File button to view a sample of the fields included in a file you can download. • Select the Download-Fite button to download a text file of your search results at no charge. • Click Pu# i inforrraIion Request;•orm to order additional data. ult CSSL- Construction Supervisor 099351 Specialty Active 02664 MA CSSL- CSSL-RF-Roofing Active South Yarmouth MA ._- 09935 t 9 02664 vP ,f , i s t CSSL- CSSL-WS-Windows and A Ve South Yarmouth MA 099351 Siding 02664 '_ar f`{ 3„ H.E-193830 Hoisting EngineerNull and Void Woburn MA 01801 HE-1 CT- elescoping Booms w/o Null:and h1E-193830 Woburn MA 01801 Cables Void Null and l#E.193830 HE-2A-Excavators Void Wobum MA 01801 CSS-104480 Construction Supervisor Null and WOBURN MA 01801 Void )&0 7§ \)\ T\ 0,9 2X ƒ/ \72 \) f)G / /) _;: o, m ■ -<Gao opo 3 §( $23 $®®% / # »)$ -g;* \ 0(mm r- \22) k $$�2 �O0 \ :2 >\\° T/ 0: !2## 2' $ = x ( 0 ( 2 {a , �kM I \ \ ■4 § 2 \ [ ` CO00 2ooe I \ \S./) ƒk / ) \0 \ !2�|7 a$f/ r 2 . 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