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HomeMy WebLinkAboutBLD-22-007379 ,.:� .Y�q�;--. ��� V�— Office Use Only .°. ,,'��1C O' 0/Z.3IZ 41 C Permit# # �94 °•� «utr H ass '�' Amount Sada mac,• e��, Permit expires 180 days from issue date 61-P gal- 73 EXPRESS BUILDING PERMIT APPLICATION— ~�� �q TOWN OF YARMOUTH Yarmouth Building Department R 1146Route28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 J U N 212022 CONSTRUCTION ADDRESS: 2 -S kite 6e( BUILDING D E PA R T M E N T or: ASSESSOR'S INFORMATION: IMap: I Parcel: DOWNER: i) be 1r f p_ ,yi Fr"© 26/ Shdt l�-e tt yai� , .n NAME PRESENT ADDRESS TEL. # CONTRACTOR: NA E ✓L'� r e 7 I� 5 i./ 4o �'/ /GPJL- d�c (�' < `(i;el-W it MAILING ADDRESS TEL.# S°GJs--,3 , 2 74, d Residential ❑Commercial Est.Cost of Construction$ 2/2S e)c i Home Improvement Contractor Lic.# / V 30 53 Construction Supervisor Lie.# 9q 3 S / Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor 4Z1I have Worker's Compensation Insurance Insurance Company Name: 4/.4 Worker's Comp.Policy# es-S S v8 0?Z'riv,g 7?71 WORK TO BE PERFORMED Tent .0 Duration (Fire Retardant Certificate attached?) Wood Stove Sidi#of Squares 5 Replacement windows:# Replacement doors: # Roofing:� #of Squares (❑)Remove existing*(max.2 layers) Insulation I I ( I I Old Kings Highway/Historic Dist. Replacing like for like Pool fencing n *The debris will be disposed of at: Y .i',,,t,e)✓th 4�'r 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. Applicant's Signature: Date: 6. /22/2p2e Owners Signature(or attachment) Date: Approved By: 7:1 Date: Cs `' 3 22 Building Official(or ee EMAIL ADDRES Zoning District: Historical District: 0 Yes D No Flood Plain Zone: C Yes C No Water Resource Protection District: Within 100 ft.of Wetlands: ❑ Yes 0 No 0 Yes 0 No The Commonwealth of Massachusetts t Department of Industrial Accidents 1 Congress Street,Suite 100 _;4§1,=j-r' Boston, MA 02114-2017 wwry 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): /k,-, ' '��>,��' Address: $ y L toe .61re,rd/s, 'r' City/State/Zip: y4 rniao Phone#: SG' -2 e) e t' Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with / employees(full and/or part-time).* 7. El New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. ©Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.01 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10❑Building addition 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 11.1DElecttical repairs or additions proprietors with no employees. 12.QPlumbing repairs or additions 5.1:I 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.t 6.0We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q 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. ,q Insurance Company Name: L /1//, Policy#or Self-ins.Lie.#: 5 4 9 e)-'2 2 to/ 37 Z 7? Expiration Date: 3 4/ 2] Job Site Address: `c S 1O'r' 1` ) City/State/Zip: \/ /2/t c: , /22 G?6e9 of the workers' compensation policydeclaration page(showingthe policynumber and expiration date). Attach a copy P F g 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 tite pains and penalties of perjury that the information provided above is true and correct. Signature: -- �'' Date: .6�.Z i / ?u'�t Phone#: 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 na Contact Person: Keating Construction141P • , Home improvement contractor registration: DATE June 20,2022 143053 54 Lower Brook Rd Quotation# 1 So. Yarmouth MA Phone(508)760 2702 timkeating66(a hotmail.com Proposal for: Job name/location: Robert Pomeroy Same 26 Shore Rd Yarmouth Ma We hearby submit specificatons and Description Strip sidewall off right side gable wall Install Typar house wrap Install clear cedar sidewall Install Azek trim around window Material supplied by homeowner All debris and trash will be removed and disposed of properly Only items specified above are included in this proposal. Rotted wood replacement is not included in this proposal Chimney flashing replacement is not included in this proposal Materials guaranteed by manufacturers. Workmanship guaranteed by Keating Construction for 10 years. We propose hereby to furnish labor and for the sum of: $2,750.00 Balance due upon completion / Acceptance of Proposal: c' { G Lt` Date of acceptance: C [ 1 S c Acceptance of Proposal: ` Date of acceptance: The above prices, specifications and conditions are satisfactory and are hereby accepted. ACC7f1't7 ki....--- CERTIFICATE OF LIABILITY INSURANCE DA THIS 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 policy(iee)must have ADDITIONAL INSURED provisions or be endorse If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,this certificate does not confer rights to the certificate holder in lieu of suh endorseme t(scies may require an endorsement. A statement or PRODUCER ). ra Nam: JIM HINDMAN Schlegel&Schlegel his Broker PHONE 34 Main Street 50&771-8381 West Yarmouth,MA 02673 arc No 508 771-066 ADDRESS: schl elinsuran maii.com INSURER S)AFFORDING COVERAGE NA INSURED INSURER A: MOUNT VERNON •TIMOTHY KEATING DBA KEATING INSURER B: CNA CONSTRUCTION INSURER C 54 LOWER BROOK RD INSURER D: SOUTH YARMOUTH,MA 02664 t� N;;RER E, COVERAGES 1 INSURER F: ^�— CERTIFICATE NUMBER: REVISIONTHIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FORMTHSE 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 ADDLSUBR lTR TYPE OF INSURANCE fNSD yyyD POLICY NUMBER POLICY EFF POLICY EXP {MIitDDryYYyI IMMIODtYYYy) LIMITS X COMMERCIAL.GENERAL 11ABILIY CLAIMS MADE OCCUR ( EACH ODAMAG RRN ED $ 1,0 PREMISES(Ea occurrence) $ 5 A NN 12325470 MED EXP(My one pew) $ 03/19/22 03H 9i23 PERSONAL a ADv INJURY $ 1,0 GEN'L AGGREGATE LIMIT APPLIES PER. POLICY a LOC GENERAL AGGREGATE $ 2,0 OTHER' PRODUCTS-COMP/OP AGG $ 2,0 AUTOMOBILE LIABILITY $ COMBINED SINGLE LIMIT $ III ANY AUTO (Ea accident) OWNED SCHEDULED BODILY INJURY(Per person) S AUTOS ONLY __ SCHEDULED AUTO BODILY INJURY(Per acadant) $ MINHIRED NON-OWNED En AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE (Per accident) S UMBRELLALIAB OCCUR $ EXCESS UAB EACH OCCURRENCE $ 1 CLAIMS-MADE. DED 1 I RETENTIONS AGGREGATE $ WORKERS COMPENSATION $ AND EMPLOYERS'LIABILITY YIN I PER [OTH- ANY PROPRIETORPARTNER/EXECU7IVE{ STATUTE I ER B OFFICER/MEMBER EXCLUDED? i N J N r A 16S59UB0224N37222 E.L.EACH ACCIDENT $ 11 (Mandatory In NH) 03/09/22 03l09123 If dIPTION under OF OPERATIONS below E.L.DISEASE-EA EMPLOYE a S 11 DESCRIPTION be E.L.DISEASE-POLICY LIMIT $ 51 f_ I 1 DESCRIPTION OF OPERATIONS I LOCATIONS r VEHICLES (ACORD 181,Additional Remarira Schedule,may be attached If more*Pace 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 AUTHORIZED REPRESENT I • i©. 2015 ACORD t__rseSSitdd , ...e.., 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 Information Request Form to order additional data. Search N m License Results Status tress, CSSL- Construction Supervisor South Yarmouth MA '. 099351 Specialty Active 02664 'Kti Ein�g. Tim B CSSL- CSSL-RF- Roofin South Yarmouth MA 099351 9 Active 02664 Kr ati:�L_ Tim B CSSL- CSSL-WS-Windows and South Yarmouth MA 099351 Siding Active 02664 :Keating Timothy -------. Null and HE 193830 Hoisting Engineer Woburn MA 01801 .__ Void_ `Keating, Timothy HE-1C-Telescoping Booms w/o Null and HE-193830 Cables Woburn MA 01801 Void Keating,Timothy HE-193830 HE-2A- Excavators Null and a__ Void Woburn MA 01801 ATIk#G Null and 1 - -J �, -- CS-104480 Construction Supervisor WOBURN MA 01801 _` Void - - _ _ c . ram ■R -<oo yo 2.*-I Ai 0 02FP §� Bk @01og f§§ 0 § i§ p�$K �k\ \% £ � �I «o y0 > § #- R E 0 /mm_< m $ kJ � 2 § 0q�X 2 \ moo.< >> /03 m 0 � �m I �002 cmf� 90q z ��k® ex =n ■ @ 77Eoc � g9� /0 � � > / \ 0 c 0 x ¥ / kcm 2 0 M n % £.1 0 0 2 -. 7■ 3 / \ - DJR = •0 ( cp cn K k = $ 7 o�°■ £ 3 K s• D m g�( = r 3 ® — ■ ��k 0 I 0� co ccv2 = e- CD O po ® -` ^ @ m = m g %c3 _- 0m$ - - £ ; »£ « 0 7 . > § M2E. mƒ 70 0c w §ak- xƒ _ a) $ 0 E 7£§ [ c k \ - $ 2 kES ) u \\\ . o _ c CO CD 2 > o m c ■ « O -. _ +ws —I a C. m c /&3. cn E 2 k 03\ k` E U 04 , at gi 2 A