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HomeMy WebLinkAboutBLD-22-007131 r �.® *YRR Lin 1, 1 g 11- _ Office Use Only j 1't/`� O' Permit# . H J® /// �ny�MATTAz., F... / Y �/ 'JAmount �O v t xA9o00...0 .-C.? .{ }Permit expires 180 days from issue date 6LD—aa -Oa 03 i EXPRESS BUILDING PERMIT APPLICA RINCEIVED TOWN OF YARMOUTH Yarmouth Building Department JUN 08 2022 1146 Route 28 South Yarmouth, MA 02664 Bul (508) 398-2231 Ext. 1261 By: N CONSTRUCTION ADDRESS: i l �C Sj;e L„ y(r.,tadi- POri /r'V"(_n ASSESSOR'S INFORMATION: ' 1 Map: Parcel: OWNER: _9 U l�l/6+i l I 4 eS h‘e G i/�y?-t.G�ti per}' IA4 NAME / PRESENT ADDRESS! /' TEL. # CONTRACTOR: t l 7 I( S 1 "tv Sif Laker &at./' 6,-,e-A4- 6 7149t, NAME MAILING ADDRESS TEL.#s-o ) CV/Residential �6 d � ❑Commercial Est.Cost of Construction$ c;, dd Home Improvement Contractor Lic.# it.,30.13 Construction Supervisor Lic.# fcJ-r/ Workman's Compensation Insurance: (check one) ❑ I am the homeowner ❑ I am the sole proprietor ❑ I have Worker's Compensation Insurance Insurance Company Name: C /l`// Worker's Polic Comp. 6 P Y# S 5S1/l30t'Z 114.)3,> 2.?Z WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares i e. (NI)Remove existing* (max.2 layers) Insulation .i Old Kings Highway/Historic Dist. (4 Replacing like for like Pool fencing *The debris will be disposed of at: (C/k1L .. vM 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 revo ation of my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: a2/2d?? Owners Signature(or attachment) / Date: Approved By: G �, Building Official(or de ' ee Dater- EMAIL ADDRESS: oning District: Historical D. trict: es ❑ No Flood Plain Zone: ❑ Yes ❑ No Water'Res rce District: Within 100 ft. of Wetlands: 0 Yes 0 No 0 Yes 0 No ,k°1 • The Commonwealth of Massachusetts r, Department of Industrial Accidents n' I Congress Street, Suite 100 "+� Boston, MA 02114-2017 ..SV'l \it,,- . www.massgo v/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): '—r;,„..., k-Pc•.nri5 Address: 5 y L 0 cr- 4,4(4 r r e . City/State/Zip: V4,"474)...iii--, keg Phone #: U 76c) ?7n Are you an employer?Check the appropriate box: Type of project(required): l.L I am a employer with / employees(full and/or part-time).* — 2.0 I am a sole proprietor or partnership and have no employees working for me in 7. — New construction any capacity.[No workers'comp.insurance required.] 8. 2 Remodeling ` 3. I am a homeowner doing all work myself. [No workers'comp. insurance required.]t 9 ❑ Demolition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my propertyI will 10 _ Building addition ensure that all contractors either have workers'compensation insurance or are sol proprietors with no employees. 11.❑ Electrical repairs or additions 5.❑ m I a a general contractor and I have hired the sub-contractors listed on the attached sheet. 12'El Plumbing repairs or additions These sub-contractors have employees and have workers'comp. insurance.t 1 •❑Roof repairs 6.❑We 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. 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: ( .4/4 Policy#or Self-ins. Lic. #: 'S 54v,3 02z..t,ii317 ? & Expiration Date: 3/S/Z3/ Job Site Address: L c:i jr°e G.` City/State/Zip: Y4/-iil vo ti-rail'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 coverage verification. insurance I do hereby certify under the pains and penalties of perjury that the information provided above is true'and correct. Signature: 4�� Date: / H 2i2e. Phone#: SiCf- 7 4 o ? 20 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Issuing Authority (circle one): Permit/License# 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Ins ector 6. Other p Contact Person: Phone#: �, -4" 'corttr CERTIFICATE OF LIABILITY INSURANCE OATE�(MI1{ MS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS 03/17/2; 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 pollcy(ies)must have ADDITIONAL INSURED provisions or be endorsrt If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement- A statement or this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRIXIUCER Schlegel&Schlegel ins Broker J1M HINDMAN 34 Main Street tNiONE 508-7Tf-8381FAX (NC.No,Earl: I(Am,No): 508-771-066 West Yarmouth,MA 02673 ADDRESS: schlegeiinsuran mali.Com INSURER(S)AFFORDING COVERAGE NA INSUREDINSURER A: MOUNT VERNON TIMOTHY KEATING DBA KEATING INSURER a, CNA CONSTRUCTION INSURER C: 54 LOWER BROOK RD INSURER D SOUTH YARMOUTH,MA 02664 INSURER E: COVERAGES CERTIFICATE F: CERTIFICATE NUMBER: REVISION THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FORMER: THBE 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.LTR TYPE INSURANCE ADOZ6U8R POLICE I POLICY EXP X GENERAL UABit.i1Y �NSD MD POLICY NUMBER MmorYVYr) COAIMERCULL LIMITS ICLAIMS-MADE El OCCUR EACH OCCURRENCE $ f,0 DAMAGE TO RENTED PREMISES(Ea occurrence) $ 5 AMED EXP(Any one person) I$ NN 12325470 03/19/22 03/19/23 GEM AGGREGATE LIMIT APPLIES PER: PERSONAL 8 ADV INJURY $ 1,O POLICY LOC GENERAL.AGGREGATE $ 2,0 ii OTHER' PRODUCTS-COMP/OP AGG $ 2,0 AUTOMOBILE LIAINUTY $ COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) OWNED SCHEDULED BODILY INJURY(Per person) $ AUTOS ONLY __ AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED AUTOS ONLY _ AUTOS ONLY Per acc,d tDAMAGE $ } i $ UMBRELLA LIAR OCCUR EXCESS UAB EACH OCCURRENCE $ I CLAIMS-MADE I DED 1 1 RETENTION$ AGGREGATE $ WORKERS COMPENSATION $ AND EMPLOYERS'LIABILITY Y/N PER ff OTH- ANY PROPRIETOR/PARTNER/EXECUTIVE STATUTE (ER B OFFICER/MEMBER EXCLUDED? N N I A 16S59UB0224N37222E.L.EACH ACCIDENT $ f+ (Mandatory in NH) 03/09/22 03/09/23 If yes describe under E L.DISEASE-EA EMPLOYEE,$ f l DESCRIPTION OFOPERATIONS beio E.L.DISEASE-POLICY LIMIT $ 51 w I Ill 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 BEF THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN TOWN OF YARMOUTH ACCORDANCE WITH THE POLICY PROVISIONS, BUILDING DEPARTMENT YARMOUTH MA r AUTHORIZED REPRESENT © 8-2015 ACORD CORPOR ATION'. All rirlhts rase - t =' . 5_A • • • xc k . ; I • :...ram.. _ ' fit. •� .. 'r.: '. � �� . ... .... i \0 f/) ;$ 0 £ < Cx /T z7k //§ // \ 0c $'/$ K2 00 _mSS 4050 /f0 3 ft © » ° f* 11 z Mn \ ƒ cJ 0-m 0 - 41. \ ; mi »A Cxi-a #r e o k 7$ }� - 0o/ 7mf-I ■q >qZ t{koc> Qp% it z0 © J /7 ktn0 00 / � g0 k n■© m2 \\ o 2? 7® g C)- CO R R 3 0 0 ® K c * c O / = - @ @ 03-10, xl 2 K - > m /0/ƒ 7 $ o ' Io77 @o =. . 3. -, r 0 _ = q 2 »0.00.2 0 = m @ 2 o CI CO A 0 CD 0. 0 °■$ 3� @ . * k§Ei k \ 0) -�§ mƒ o _k;en \� -k - _ CD CD m �' 7 \\� - $ 2 02 $/�) O. kf7 O 0 C eD ; > (0 M c ■ E 723 c ƒ g 2¥$ CO w [ 2 tit \ _/ 0 = X A ; o ■ a • 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 Facility 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 File button to download a text file of your search results at no charge. • Click Public k n Request Form to order additional data. Search Name Results ,i f,e i- CSSL- Construction Supervisor Active South Yarmouth MA 099351 Specialty 02664 -ant' Tim R. 09935i CSSL-RF-Roofing Active South Yarmouth MA 02664 43,Tom_S 'CSSL- CSSL-WS -Windows end South Yarmouth MA 099351 Siding Active 02664 eat ' Timothy 'HE-193830 jHoisting Engineer !Null and Woburn MA 01801 eat' Timothy iHE-193830 IHE-1 C-Telescoping Booms w/o Null and !Cablesobum MA 01801 I Void I K tmg, Timothy HE-193830 HE-2A Excavators [Null and Coburn MA 01801 -. _ __ Void ' CS-104480 Construction Supervisor Null and 'WOBURN MA 01801 t 'Y F p Void 6/9/22, 11:18 AM Details Licensee Details Demographic Information (Full 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: Profession: Building Licenses Date of Last Renewal: 5/4 20 gS -Windows and Siding Issue Date: 4/27/2012 Expiration Date: 5/11/2024 License Status: Active Today's Date: 6/9/2022 Secondary License Type: Doing Business As: Status Change Reason: License Renewal Prerequisite Information Licensee: Keating, Tim B Relationship: Attribute Of License No: CSSL-099351 No Available Documents https://madpl.mylicense.com/Verification/Details.aspx?result=7644d72e-1360-4807-b0eb-2eb92de4e9a0 1/1 i. . z .\