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HomeMy WebLinkAboutBLDX-25-1275 8 +pX as-ia`IS Q EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 (508)398�--2231 Ext. 1261 y6rmediti CONSTRUCTION ADDRESS: t74, -- J in1 C P L A OWNER: 76 \l e l,-(yh4-body 8' T4 4 - D.SlNV Li'4( y4 i/"cY t - NAME PRESENT ADDRESS f� '/ ,yTEL. ft CONTRACTOR: -f(M k'P4±..n5 ,S T l�Ot/.Z'!'R!(Jy v (re UC(/✓NI ot, G �-_ �% NAME MAILING ADDRESS tt TEL 4 • O,- 7 6 C,lw EMAIL: ' l tM I(044,'1)5 L1o4n,4, /•(dM ❑Residential U Commercial i_Est.Cost of Construction$ I Y Ud Homeowner is Applicant? Yes No Home Improvement Contractor Lic.# I Y 3 0 ; Construction Supervisor Lic.it Cf j 35/ WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate required) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares 2.y 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: Y4711 O i(Zi 111/4 Location of Facility 1 declare under penalties of perjury that the statements herein contained are true and correct to the best of my knowledge and belief. 1 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 I. Applicant's Signature: Date: 2, YI 2 f Owners Signature(or attachment) Date: Approved By: Date: Building Official(or designee) Rev 6/24 Keating Construction Home improvement contractor registration: DATE August 5,2025 143053 Quotation# 1 54 Lower Brook Rd So.Yarmouth MA Phone(508)760 2702 timkeating66 aC�hotmail.com Proposal for: Job name/location: Julie Lightbody Same 8 Tam-0-Shanter Way Yarmouth Ma 02664 We hearby submit spectficatotis and Strip roof shingles off entire house and shed roof Install Certainteed ice+water shield on all lower edges,chimney and valleys Install Certainteed Roof Runner Paper Install new vent pipe flanges Install white 8 inch drip edge Install Certainteed Landmark 30 yr architectural shingles Install ridge vent on entire peaks 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. Materials guaranteed by manufacturers.Workmanship guaranteed by Keating Construction for 10 years_ Wepropose hereby to furnish materials and labor for the sum of$12,400.00 1/3 balance due at start of job Acceptance of Proposal: Date of acceptance: Gll lb/2.f Acceptance of Proposal: Date of acceptance: The above prices,specifications and conditions are satisfactory and are hereby accepted. L� The Commonwealth of Massachusetts Department of Industrial Accidents ? +(7 Office of Investigations Lafayette City Center 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): t T ►'17 A---- 4.- 7' Address: 5 y Z ow et— 6/wI✓ t'e City/State/Zip: y4l M pJ OZ l: Phone#: S&c 7 6C 0 70? Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with / 4. ❑ I am a general contractor and I 6. ❑New construction employees (full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. [f Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.: required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.]t c. 152,§1(4),and we have no employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box#1 must also till 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. 1Contractors 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: /t/A Policy#or Self-ins. Lic.#: C Z Z YiV37Z Expiration Date: 3/5'/U. Job Site Address: ' f41'i` o-sf-tA!'Vf eie (✓4y City/State/Zip: y4/f5119.)'>'f' O2& - 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 S1,500.00 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 t epains and penalties of perjury that the information provided above is true and correct. Signature: f/ Date: V2Y Phone#: 5 766 2 7 4) 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 3❑City/Town Clerk 4.❑Electrical Inspector 5Elumbing Inspector 60Other Contact Person: Phone#: �_..�"'..411 TIMOTHYKOI AREGULA ACORN CERTIFICATE OF LIABILITY INSURANCE DATE 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 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 CONTACT NAME:W 34 a Insurance Associates, LLC i PHONE Ext): (508) 771-8381 FAX No):(508) 771-0663 34 Main St. - - West Yarmouth, MA 02673 tADDRESS;_-_ , INSURER(S) AFFORDING COVERAGE i NAIC# _ INSURER A:Nautilus Insurance Company_ 17370 INSURED INSURER B:Continental Casualty Company 20443 TIMOTHY KEATING DBA KEATING CONST _INSURER C: _ 54 LOWER BROOK RD INSURER D: SOUTH YARMOUTH, MA 02664 - - - — - INSURER E INSURER F : 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. INSR TYPE OF INSURANCE .ADDL:SUBR POLICY NUMBER POLICY EFF I POLICY EXP LIMITS LTR I INSD i WVD (MMIDDIYYYY) (MMJDD/YYYY} A x COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE I $ 1,000,000 CLAIMS-MADE IX , OCCUR INN1675006 3/19/2024 3/19/2025 DAMAGE TO RENTED I 50,000 I PREMISES (Ea o�currencea $ 5,000 MED EXP(Any one person) $ ___ PERSONAL&ADV INJURY I $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE I $ 2,000,000 PRO- 2 000,000 POLICY i i JECT LOC LPRODUCTSCOMP/OPAGG I $ 1 OTHER: -- I $ --- — AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT I .(Ea accident1 --a — I I ANY AUTO BODILY INJURY(Per person) I $ OWNED ( 1 SCHEDULED i AUTOS ONLY I , AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY 1 i AUTOS ONLY i Per accident) __.._.r._$ i t $ UMBRELLA LIAB OCCUR EACH OCCURRENCE i $ EXCESS LIAB I CLAIMS-MADE AGGREGATE , $ DED RETENTION$B ( $ :WORKERS COMPENSATION X + PER ' OTH- AND EMPLOYERS'LIABILITY Y!N STATI�TE� I ER.__..-. I 0224N372 3/9/2025 3/9/2026 i100,000 ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT _ ! $ I OFFICER/MEMBER EXCLUDED? N N l A 1 100,000 i(Mandatory in NH) E.L. DISEASE-EA EMPLOYEE; $ _ If yes,describe under 500 000 DESCRIPTION OF OPERATIONS below I E.L. DISEASE-POLICY LIMIT I $ ' 1 1 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES ACORD 101,Additional Remarks Schedule, maybe attached if more space is required) INSURANCE COVERAGE 13 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 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Cape Symphony ACCORDANCE WITH THE POLICY PROVISIONS. 2235 lyannough RD West Barnstable, MA 02668 AUTHORIZED REPRESENTATIVE i I `(} ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Commonwealth of Massachusetts Construction Supervisor Specialty 7101 Division of Occupational Licaesure Board of Building Regulations and Standards Restricted to: Construc'.j°}hC- ir'Yj-'Specialty cssL ws Windows and Siding '7 s CSSL-099351 fkpires:05/11/2026 TIM B KEATI�G 54 LOWER BROOK ROAD 3 SOUTH YARF )UTH MA 02664 O2' 0 a • '`h07.LY3il2' Failure to possess a current edition of the Massachusetts State '/ Building Code is cause for revocation of this license. Commissioner e W s1_ Contact OPSI:(617)727-3200 or visit www.mass.govldpl/opsi :i :unacaaoM to Ri6wvnomnro� r-oiJ I6noltsquaao to noi2ir0 zhl,, • ,t::ns::9oit6iu e51 gnibllu8 to hiuo8 aTkt..W4"IQtt�UV2o.�J aa0>1tt1z0 e-nitixst raCeeo-J aD l � H•,? ienotasimmo3 THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration * Z \-0. (10 4I SI = ; " r` Type: Individual .... Registration: 143053 TIMOTHY KEATINGsff Expiration: 06/13/2026 D/B/A KEATING CONSTRUCTION *•-• 0 + 54 LOWER BROOK RD. 1111111 rat AM.` '""" =- • or SO. YARMOUTH, MA 02664 \e4; T"'"' .i illir ;°fir .. 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 .4. - ;.v ' j.---, • ' ..p i p TVs '!rl 54 LOWER BROOK RD. SO. YARMOUTH, MA 02664 Undersecretary Not valid without signature