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HomeMy WebLinkAboutBLD-22-007464 LIT) f �y- Office Use(Ln M Only �^ Permit# A ) c:. Lilt I &l IJp -4 y Amount COC :�J,"` ••+�" Permit expires 180 days from issue date 6CD g — O LU,L( EXPRESS BUILDING PERMIT APPLICATIONC E ! V E D TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 JUN 28 2022 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 BUILDING DEPARTMENT B y' CONSTRUCTION ADDRESS: 6 ' u© / S 13,E Yc,(7-10,)74 ASSESSOR'S INFORMATION: Map: Parcel: I° / 61 r �s l/trial OWNER: lM ����1✓15 U�v D ��v� l NAME / PRESENT RESS TEL # CONTRACTOR: -1 ' n'/ n P 5�1✓'� .S L-/ L Ow e, Bra Brax,r 1 4701 c OP"- NAME MAILING ADDRESS TEL# ref dResidential ❑Commercial Est.Cost of Construction$ D 6 a Home Improvement Contractor Lic.# I Ll 3t: s Construction Supervisor Lic.# �j`7. 2 Workman's Compensation Insurance: (check one) 0 I am the homeowner ❑ II am the sole proprietor 0 I have Worker's Compensation Insurance Insurance Company Name: C jd� ' Worker's Comp.Policy#t;S 5/v J O 2 2 S 7 2?? WORK TO BE PERFORMED Tent E Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares 1 A (❑)Remove existing*(max.2 layers) Insulation n n Old Kings Highway/Historic Dist. a)Replacing like for like Pool fencing 'The debris will be disposed of at: YL;(-73-7 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 my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: 6/Zz<J?d Owners Signature(or attachment) Date: Approved : Date: PP B Y Building Official des' e) EMAIL ADDRES : Zoning District: Historical District: ❑ Yes 73 No Flood Plain Zone: C Yes C No Water Resource Protection District: Within 100 ft.of Wetlands: D Yes O No ❑ Yes 0 No The Commonwealth of Massachusetts cl_ I Department of Industrial Accidents ::%i1= 1 Congress Street, Suite 100 .44 c" tt j boston, MA 02114-2017 r.A1f `.E wwn.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): —re;tri k e 4 /-,>1 Address: S L/ L-G) l31"ci`7I. rf City/State/Zip: vi,1'vi,c !7L. fuLA O 26 7 Phone#: Sc a- 7so 2 )ci .-- Are you an employer?Check the appropriate box: Type of project(required): I.12:1I am a employer with i employees(full and/or part-time).* 7. ❑New construction 2.ElI am a sole proprietor or partnership and have no employees working for me in 8. Er Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp_insurance required.]t 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 El Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0Electrical repairs or additions proprietors with no employees. 12.Q Plumbing repairs or additions 5.111 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 theirright of exemption per MGL c. 14.QOther 152,§1(4),and we have no employees. [No workers'co p.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: C_/i"4 Policy#or Self-ins.Lic.#: (.S y,.) g O 724 4-'3) Z 72 Expiration Date: 3 /5 / ? 3 Job Site Address: 6 / t' D , l '3/ia/vo City/State/Zip: c 6-'hD � ( . Attach a copy of the workers' con}pensation 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 pains and penalties of perjury that the information provided above is/ true and correct. Signature: /Date: ,i ze 2 c}Z 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): I.Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: Keating Construction `: Home improvement contractor registration: 143053 DATE May 31. 2022 54 Lower Brook Rd Quotation# 1 So. Yarmouth MA 02664 Phone (508) 760 2702 Proposal for: Tom Catarina Job name/location: 61 Iroquois Blvd Same Yarmouth Ma 413 530 8360 We nearby submit specificatons and Description 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 white 8 inch drip edge on all eves Install Certainteed Landmark 30 yr architectural shingles Install ridge vent at all peaks Remove front skylight and fill in hole with plywood 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: S6,950.00 Senior Citizens discount included 1 payment due at start of job and remainder upon completion Acceptance of Proposal: L 4 Acceptance of Proposal: � , - Date of acceptance: �_• lte of acceptance: iithis The above prices. specifications and conditions are satisfactory and are hereby accepted. A► olra CERTIFICATE 4F LIABILITY INSURANCE DATE(MMlDDi THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. 117 03117/2' RTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES CE BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED AU THIS REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the li ies must have ADDITIONAL INSURED provisions or be endorse If SUBROGATION IS WANED, 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(:). PRODUCER NAME: JIM HINDMAN Schlegel&Schlegel Ins Broker 34 Main Street P►NONE t�ALC.No.Ertl• 508-771-8381 West Yarmouth, MA 02673 ADDREss: schlegelinsuran mall.com Am Nor 508-771-06s - . INSURER(S)AFFORDING COVERAGE INSURED INSURER A MOUNT VERNON NA TIMOTHY KEATING DBA KEATING CONSTRUCTION 54 LOWER BROOK RD INSURER D SOUTH YARMOUTH,MA 02664 ; INsuRER E i 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 PE RI 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 OF INSURANCE I W COMMERCIAL GENERAL LIABILITY VD POLICY NUMBER MM//DD ' M�DOJYVYt LNMITS lCLAIMS-MADE ® OCCUk EACH OCCURRENCE S 1,0 u PREMISES'Ea occurrence' S 5 A -- NN 12325470 MED EXP{Any one person) S GEN'L AGGREGATE LIMIT APPLIES PER. 03/19122 03/19/23 PERSONAL!L ADV INJURY s 1,0 P POLICY I ECT I LOC GENERAL AGGREGATE I$ 2,0 OTHER ! I PRODUCTS-COMPrOP AGG S 2,0 AUTOMOBILE LIABILITY $ COMBINED SINGLE LIMIT ANY AUTO Ea accident) S OWNED SCHEDULED BODILY INJURY(Per person) I $ AUTOS ONLY AUTOS 1-- HIRED NON-OWNED BODILY INJURY(pe acc den)?I S AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE(Per am dent) I$ UMBRELLA LAB j OCCUR f I li$ EXCESS LAB j CLAIMS-MADE EACH OCCURRENCE I S DED I 1 RETENTIONS I AGGREGATE i S if WORKERS COMPENSATION S AND EMPLOYERS'LIABILITYI PER OTH- YiN STATUTE ER ANY PROPRIETORPARTNEREXECUTIVEr— B OFFICERIAEMBER EXCLUDED? I N N/A 16S59UB0224N37222 E.L.EACH ACCIDENT' (Mandatory In NH) I 03109122 03l09l23 $ 1i 1 It es,describe under J E L DISEASE-EA EMPLOYEE S 11 DESCRIPTION OF OPERATIONS below }E L.DISEASE.POLICY LIMIT S 51 I f) i # I I i t I ' i I DESCRIPTION DF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Addklonal 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 AUTHORIZED REPRESENTV1 111 i • Select the licensee name below for more information. 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ICeaiiry T€ B CSSL- Construction Supervisor Active South Yarmouth MA 099351 Specialty 02664 _ . m !<eating Tiny-B CSSL- CSSL-RF- Roofing Active South Yarmouth MA 099351 02664 e ting, Tim B CSSL- CSSL-WS-Windows and Active South Yarmouth MA 099351 Siding 02664 eating, Timothy HE-193830 Hoisting Engineer Null and Woburn MA 01801 Void Keating, Timothy HE-193830 HE-1C-Telescoping Booms w/o Null and `Woburn MA 01801 Cables Void ea ing, Timothy HE-193830 HE-2A- Excavators Null and 1Woburn MA 01801 Void KEATINGTIMOTHY-F CS-104480 Construction Supervisor Null and WOBURN MA 01801 Void 8Tg g- -<oo Do � o Km� D� n_ UP -1X m m Cn0 o-I ��� Z = D n O;'mg SOD G7� 3 n -<ODO Kx=1 O0 y0 m = 3 >*x2 D00 m wu -a 3 z 3'��o Z T o wo < an -',7GZ•)� 0 �,. --t 2 rn LC m- 0Oz 1 'it! Z °-Z m o y 73 Z �: €1 � o m Z 90-n 0 Cn V y*. 4,s 11� 0,x a f) W 3 0. 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'6 O o-o p 73 C rh //� O j W o• w m CD V, Ca. ow ' A .. o CD m 5 o = C i 0 a �a CD 0 7 W G c 7 n so FL 6/28/22.3:29 PM 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: Construction Supervisor Specialty Profession: Building Licenses Date of Last Renewal: 5/24/2022 Issue Date: 6/4/2008 Expiration Date: 5/11/2024 License Status: Active Today's Date: 6/28/2022 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 https://madpl.mylicense.comNerification/Details.aspx?result=9c370120-2f9f 463f-af34-8264a15d02dd 1/1 Y p �m D DO CCa E w 33; c it 2 ff\ o= 33 Ea., • N 0 N . 1 a u`� w v , ` 0 4 Itc iri H . ` a. u..J to \'4ti1(jA.� to J to fq C �i�et ",IC vas in �� rn w gY. 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