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HomeMy WebLinkAboutBLDX-25-1188 AT- EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Bung Department 1146 Route 28 South Yarmouth,MA 02664 G n (509 3 -"3! Ext. 1261 CONSTRUCTION A : O lJ r4/tie Or yii ri4-7!'✓`l'L CM 7 OWNER J- r^C V✓ It'IG !V.% l/i7 E 1s!4t//e" f;04 NAME PRESENT ADDRESS TEL. 1, �fl-, A.-7e<t)nl S`/ LUG J &c, r 7 4i"'wh t4,/I D 25 NAME MAILING ADDRESS TEL 4S6 c f 2t<d ?7 02 EMAIL: �'.os�,n f 66® hit (s l< C or), dResidential 6A Q Commercial F_Est.Cost of Construction$ Ls,SW) Homeowner is Applicant? Yes No Home Improvement Contractor Lic.# 1 3 0S3 Construction Supervisor Lic.# WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate required) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares 30 Insulation Temporary Mobile Home Temporary Construction Trailer Demolition—Interior only Demolition Raze Structure Solar System ESS System Chimney Fence *Please submit utility disconnect letters for electric&gas-structures over 75 years old require historical review *The debris will be disposed of at )6r/.YIaSi, W(", 9 Locato4 oTFacibty 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 revoc 'on of my license and for prosecution under M.G.L.Ch.268,Section I. Applicant's Signature: Date: g1 /'Z✓ Owners Signature(or attachment) Dom: Approved By: Date: Building Official(or designee) Rev 6124 The Commonwealth of Massachusetts Department of Industrial Accidents : �r/b t:=. Office of Investigations Lafayette City Center lX, 2 Avenue de Lafayette,Boston,MA 02111-1750 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: 5'i 1-aux/ gag. rQ} Ci /State/Zi : larni G Phone#: -5 * 76a 22a' Are you an employer?Check the appropriate box: Type of project(required): 1.©lam a employer with 1 4.0 I am a general contractor and I 6. El New construction employees(full and/or part-time).' have hired the sub-contractors 2.❑1 am a sole proprietor or partner- listed on the attached sheet. 7. 2-Remodeling shipand have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. employees and have workers' insurance.: El Building addition [No workers'comp.insurance comp. required.] 5.❑We are a corporation and its 10.❑Electrical repairs or additions 3.❑I am a homeowner doingall work officers have exercised their 11. Plumbingrepairs ❑ or additions myself.[No workers'comp. right of exemption per MGL 12❑Roof repairs insurance required.]+ c.152,§1(4),and we have no 13.0 Other employees.[No workers' comp.insurance required.] 'Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they am doing at work and then him outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the subcontractors 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/V Policy#or Self-ins.Lic.#:0 ZZ L A/3 7 Z Expiration Date: 3I Sl2-4( Job Site Address: >( 6rnnF!'1e'•0/' City/State/Zip: yult4d)rt Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c.152 can lead to the imposition of criminal penalties of 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Sienaturc: —— Datc: /L 5 Phone#: S08- 7w Z Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(check one): 1❑Board of Health 20 Building Department 30City/Town Clerk 4.0 Electrical Inspector 5E'lumbing Inspector 6.0Other Contact Person: Phone#: I*-:ir Commonwealth of Massachusetts Construction Supervisor Specialty Division of Occupational Licensure Board of Building Regula yytions and Standards Restricted to: COnstrut;ti Cup l�$y r Specialty CSSL-RF-Roofing CSSL-WS-Windows and Siding CSSL-099351 x _n.0 ecpires: 05/11/2026_ TIM B KEATIOG ;�, 54 LOWER BROOK ROAD SOUTH YARMOUTH MA 02664 -4" Er' 't 4 lO 0/,r,v3':1.1- Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. Commissioner evd.45 Contact OPSI:(617)727-3200 or visit www.mass.govldpllopsi „. £Ta9P1/Ii)R82£M SO titR9Wnomro i 1%I n9:)1 J 1sno Nsgnavl h,not Elwa •he: n:Gnc7?,b7s znoitslpReA enibllua la b)Ro8 sfr. a ss rnZO t2CePO-Jezo � +5 417A31c!8 MI' . Noote nwo s: +3ti s•.',..-:, NAYNTUQ2 isnoiazimmo3 __ THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration fr4 1.,141 - i • Type: Individual TIMOTHY KEATING Registration: 143053 D/B/A KEATING CONSTRUCTION ' Expiration: 06/13/2026 54 LOWER BROOK RD. SO. YARMOUTH, MA 02664 Update Address and Return Card. THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs & Business Regulation Registration valid for individual use only before the HOME IMPROVEMENT CONTRACTOR expiration date. If found return to: TYPE: Individual Office of Consumer Affairs and Business Regulation Registration Expiration 1000 Washington Street - Suite 710 143053 06/13/2026 Boston, MA 02118 TIMOTHY KEATING D/B/A KEATING CONSTRUCTION TIMOTHY B. KEATING 54 LOWER BROOK RD. �I.)�" „:-` � S; : SO. YARMOUTH, MA 02664 _ Undersecretary Not valid without signature AC'ORIf) TIOTHYI{01 AREGULA 1/4...-- CERTIFICATE OF LIABILITY INSURANCE DATE{MM/DDlYYYY) 3/6/2025 ! 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 POLICIESI 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 CONTACT World Insurance Associates, LLC I-NAME: 34 Main St. PHONE (AIC,No, Ext): (508) 771-8381 FAX we West Yarmouth, MA 02673 E-MAIL — ------ (ac,No):(508) 771-0663 ADDRESS:-_ INSURERS)AFFORDING COVERAGE NAIC# INSURER A:Nautilus Insurance Company 117370 INSURED INSURER B:Continental Casualty Company 20443 TIMOTHY KEATING DBA KEATING CONST INSURER C: 54 LOWER BROOK RD SOUTH YARMOUTH, MA 02664suRER D _INSURER E : INSURER F : I COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS 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. 1NSR ADDL SUER' — LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER POLICY EFF 1 POUCY EXP- A (MN!!DD/1'YYY) (Ml�tlDD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 1 CLAIMS-MADE DX OCCUR NN1675006 3/19/2024 3/19/2025 DAMAGE c0 RENTED PREMISE,. (Ea occurrence) $ 50,000 MED EXP An one rson) $ 5,000 PERSONAL&ADV INJURY $ GENT AGGREGATE LIMIT APPLIES PER: POLICY I I PR0. I GENERAL AGGREGATE 2,000,000 1_.____..1 JECT LOC I ------ ---------- PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: -- AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT I OWNED SCHEDULED (Ea accident) $ ANY AUTO BODILY INJURY�Per�rsoJi $ AUTOS ONLY AUTOS HIRED NON-OWNED BODILY INJURY(Per accident) $ —— —--, AUTOS ONLY AUTOS ONLY PROPERTY AMAGE L — ~ Per accident UMBRELLA LIAR OCCUR 4 $ EXCESS LIAR _ I CLAIMS-MADE EACH OCCURRENCE I $ � DED RETENTION$ AGGREGATE $ • f B .WORKERS COMPENSATION $ AND EMPLOYERS' LIABILITY X ' PER ER Y/NI STATUTE _._ -_ER ANY PROPRIETOR/PARTNER/EXECUTIVE !—� 1,141A. I 0224N372 3/9/2025 3/9/2026 100,000 OFFICER/MEMBER FXCI IJDFn7 i N i E.L. EACH ACCIDENT $ I(Mandatory in NH) � If yes,describe under i E.L.DISEASE-EA EMPLOYE $ 100,000 j DESCRIPTION OF OPERATIONS below I 500'000_ E.L. DISEASE-POLICY LIMIT $ I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule, may be attached if more space is required) INSURANCE COVERAGE IS LIMITED TO THE TERMS, CONDITIONS, EXCLUSIONS, THER LIMITATIONS AND ENDORSEMENTS OF THE POLICY CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Cape Symphony THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN 2235 lyannough RDACCORDANCE WITH THE POLICY PROVISIONS. West Barnstable, MA 02668 AUTHORIZED REPRESENTATIVE 4CORD 25 (2016/03) 1988-2015 ACORD name and logo are registered marks o$ ACORD CORPORATION. All rights reserved. ACORD Keating ConstructionAi Home improvement contractor registration: DATE August 28, 2025 4•.)nr.b vV Quotation# 1 :Y4 t_Uwei DI OO r'U So.Yarmouth MA Phone (b08) /6U 27112 timkeatinc166hotmail.com Prnnnsal fnr• .loh name!location- John McNally Same R ammo nr Yarmouth Port Ma 02675 ur_ .__..�•�;a_ _ea.__a_.�_ _.� ��.„+...wyw3 .swr`r.r,i.ti.+l.nti.w.rLr�..vw-vv w a�r� Strip roof shingles off entire house Install Certainteed ice+water shield on all lower edges,chimney ,skylights and valleys Install Certainteed Roof Runner Paper install new vent pipe flanges o.,, :.....L. .J..:... ....... ...1.................}•V,. .. Install ('.PrtaintPPrl I anrimark AO yr architPet►►ral shinnlPs Install ridge vent on entire peaks Install snap in gutter guards 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 renair is not inr•l►► tad in this nronncal Materials guaranteed by manufacturers. Workmanship guaranteed by Keating Construction for 10 years. We propose hereby to furnish materials and labor for the sum of;15,500.00 its aeposit aue at start of job, fj ii/li/V Acceptance of Proposal d Date of acceptance: Acceptance of Proposal. ` Date of acceptance: Than nhnvo nriroe enorifirotinne onri rnnrtitinne Oran entiefortnnr nnrt nrn horoh,, orr•onto4