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HomeMy WebLinkAboutBLDX-25-1583 yA Office Use Only itv;.„, C Permit#QL.OX—ate—i s 8'3 Amount"� C Yte,C. a�-40 �,�cOAPORATEO fib' EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 DEC 2025 South Yarmouth, MA 02664 (508)398-2231 Ext. 1261 � CnNS��NCiCT10N e!t?TIRE,SS: � v. y6e,, ,J-/-1, OWNER: C..—re [ 9� I.r7�Ps tc l Ci�/✓Jr�/h NA PRESENT ADDRESS ( TEL. # CONTRACTOR: 1 1 ✓ri A*h S Sy L 1JQ/ Ofooa> 1�'!�l✓JOJ �'l/' NAME MAKING ADDRESS TEL Sow 7‘e EMAIL: Ti,vi ee6'1 rS ' y ) /- /e edi2 klif Residential ❑Commercial L Est.Cost of Construction$ I O s O Homeowner is Applicant? Yes No u-1 Home Improvement Contractor Lie.# l ! 3e f 3 Construction Supervisor Lic.# ' f I WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate required) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofi #of Squares 5 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: 6 01) PVC /// 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 1 understand that any false answer(s) will be just cause for denial or revocation of y license and for prosecution under M.G.L.Ch.268,Section I. Applicant's Signature: Date: /L I Z Owners Signature(or attachment) Date: Approved By: Date: Building Official(or designee) Rev 6/24 The Commonwealth of Massachusetts Department of Industrial Accidents '' z -_ h Office of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston,MA 02111-1750 ' ' Of � www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): - -1 /[/'t'c n< Address: S i `/),,e)t,_, J3r1L, f) City/State/Zip: </4(7 ? 7L ! cifd) Phone#: SO ?64 2.--)0?Are you an employer? 'heck the appropriate box: Type of project(required): 1.J I am a employer with 1 4. 0 I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction listed on the attached sheet. 7. 0 Remodeling 2.❑ I am a sole proprietor or partner- ship and have no employees Thy sub-contractors have 8. ❑Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.* 9 ❑Building addition required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions officers have exercised their 11.0 Plumbing repairs or additions 3.❑ I am a homeowner doing all work myself. [No workers' comp. right of exemption per MGL YP 12.0 Roof repairs insurance required.]t c. 152,§1(4),and we have no employees. [No workers' 13.0 Other 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. lithe sub-contractors have employees,they must provide their wrorkess'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/A Policy#or Self-ins. �Lic.#: D Z ZLl y 3 1Z, Expiration Date: 3f 5/2- Job Site Address: ? 134 R? /,&'elf frfiz4A, City/State/Zip: I,"'f� (7-a/-�e..tJA GvgA 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. 1 do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: /z1 Z/ 2 f.-- Phone#: br ) ‘!r 26/Z ' Official use only. Do not write in this area,to he completed by city or town official. City or Town: Permit/License # 4 Issuing Authority(check one): 10Board of Health 20 Building Department 3tJCity/Town Clerk 4.0 Electrical Inspector 50Plumbing Inspector 6.0Other Contact Person: Phone it: ___`"....41„ TIMOTHYK01 AREGULA A �RL� CERTIFICATE OF LIABILITY INSURANCE DATE s,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 doesnot confer rights the certificate holder in flee such endorsem ent(s� certificate to certificate_ ,,. ofccc nisj. PRODUCER CONTACT NAME: World Insurance Associates,LLC PHONE 34 Main St (ac,No,Ncxt) (508)771-0381 FAX pm, 771-0663 West Yarmouth,MA 02673 ADDRESS: INSURERS)AFFORONGCOVERAI E NAIC NI INSURER A:Nautilus Insurance Company 17370 INSURED INSURER la:Continental Casualty Company 20443 TIMOTHY KEATING DBA KEATING CONST NSURERC: 54 LOWER El.ROOK EW SOUTH YARMOUTH,MA 02664 INSURER-0 INSURER E •ISURERF: 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 CONDRION 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, 1 EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE I�BISD MND POLICY NUMBER N SUBR POLICY POLICY EXP LIR ► IWND/YTYYY) UMITS A X COMMERCIAL GENERAL LIABILITY ! EACH OCCURRENCE $ _ _ _ 1,000, CLAIMS-MADE X OCCUR NN1675006 3/19/2024 3/19/2025 DAMAGE TO RENTED 50,000 PREMISES(Ea oocurerrcel E_ MED EXP(Any one person) $ _- 5, PERSONAL&ADV INJURY $ GEM.AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 1$ 2,000,000 POLICY! PRQ ' JI LOC PRODUCTS-COMP/OP AGG $ - 2,000,000 OTHER: } $ CINED AUTOMOBILE LIABILITY (EaaccidentSWGLE LIMIT $ ANY AUTO BODILY INJURY(Per person) $ OWNED 1 1 SCHEDULED ' AUTOSUTp ONLY _ NAUpTOOSS BODLY INJURY(Per accident) $ AUTOS ONLY 1__ AUTOS ONLY er accklent _ $ i i i UMBRELLA UAB _OCCUR EACH OCCURRENCE $ i EXCESS DAB CLAIMS-MADE AGGItE(iAit $ 1 DED RETENTION i $ B WORKERS COMPENSATION X PER OTH- AND EMPLOYERSLIABILITY STATUTE I ER !OFFICER/MEMBER EXCLUDED? N ANY PROPRIETOR/PARTNER/EXECUTIVE Y//N 0224N372 EL.EACH ACCIDENT i 'IU0+ 1 I N IA (Mandatory in NH) - I EL DISEASE--EA EMPLOYEE$ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY UMIT i 5�,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached it more space is required) INSURANCE COVERAGE IS LIMITED TO THE TERMS,CONDITIONS,EXCLUSIONS,OTHER r IU1TATIONS 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 ACCORDANCE WITH THE POLICY PROVISIONS. 2235 lyannough RD West Barnstable,MA 02668 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 4 islv urtcj t;anstruction Koff,*,*in `e 4 a. lr regitAration. DATE 1443vember i4..2025 Cs * ? So'.Yarmouth MA Phone( )760 2702 timkeating66( hotmail.com Proposalfor: ap, Job names location: Grek Kali Same &�,At- 4' West Yz.,rinouth Ma 0Z T3 We hereby submit spedreeettons and 1r0 roof aiiiitjles'OW fiord urhoose oniy Install Certainteed Roof Runner.Paper and mite 8 inch di*eckte Install architectural roof shingles Install ridge vent on entire peaks Supply tar papers r am:tcestmeAtenp edge,migc:.:,, ,, It>3:G^ liQ' km ' ilfar. via Yii#! :rf AR deter and trash will be remote and disposed of property Ontv gems sed above are.-tr .xn Mils proco%at Chimneys flashing replacement is not included in this proposal Rotted wood repair is ram .. i Materials guaranteed by manufacturers.Workmanship guaranteed by Keating Construction for 10 years. s"We,prsop,v�_hereby to furnish listed materlal.dump tee and labor for the sum of$1,8550.00 • Acceptance of Proposal: t rt;P 144 Date of acceptan 12I1ffO25 Acceptance of Probe€- Date of acceptance: The e . 9s '4 M!cnhditions are sate fctary and are he is' Commonwealth of Massachusetts Construction Supervisor Specialty \- Division of Occupational Licensure Board of Building Regulations r Specialty CSSL RF-Roofing .,-. CSSL-WS-Windows and Siding CSSL-099351 �w l spires: 05/11/2026 TIM B KEATI]G a 54 LOWER Bit'OOK ROAD 5 SOUTH YAR UTH MA 02664 O r O �4Uf,LVd1>>r) Failure to possess a current edition of the Massachusetts State r Building Code is cause for revocation of this license. Commissioner ev L f Contact OPSI:(617)727-3200 or visit www.mass.govldp(Iopsi atfeaonoeaaaM to rltbewnorrmo3 esii ianoneq riot noiaiv4 .nn t t^brit.znoffalo eA Q mbfl 810 buo. "�•.. t ,..qC eOdfl'f94u y, '=_nCJ asoso rtao r2L2f6J223 }c c, .mK aria m •S•''; .r .a. .... .m00- . - . lanaigairnmo3 THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs and Business Regulation 1000 Washington $trei. t - Suite 710 Boston, Massachusetts 02 11 8,, Home Improvement Contractor Registration •5 - �. ..ems. �.. t 7MMIIIIII(r" =1:, , -, ......., I(;$3 +M1 y . MIIIIIMM PI 4"1111F ,* I Type. Individual mmolowilow'"» ' ... ..: " ,eg stration. 14 305�3 TIMOTHY KEATING „Ii D/B/A KEATING CONSTRUCTION Expiration: 06/13/2026 54 LOWER BROOK RD, 0111 � MM lilll r"""""frommo suro ''a.n.�Ma.... .YIWO' rw.WIMB'•....04WMOVAP ..a INPIAMr►:.,...I:;:ll'A .4...r: w1.,!y. SO. YARMOUTH, MA 02664 , .s.7.Mirr •. ,....illM1~.z1..0011~~-f2..rP.1a..Mr:i.Mr'0..44,1&9.Rl10w.:wnWAN 'IMr .W, R�vWy3i 1 , N.w.1 Iirwmar Y! ►Aowwww-ilmar ..4".•?"Otfr"Warice'"' . "1"r00. W 244* y� �n :�'� a�w.wnrsin..rwi.w/RIl�.Mws+pn�..M.1i..w,r;,q+�.1'.a1.ww.ra+�al:::rr.wr;,Ir.•r•frMr,.?rl. tp y Update Address and Re'urm Crr� . THE COMMONWEALTH -OF MASSACHUSETTS Office of Consumer Attain; & Business Regulation Registration valid for individ&ral use only before the HOME IMPROVEMENT CONTRACTOR expiration date. If found return to: TYPE: Individual Office of Consumer Affairs and Business Regulation Ealitatkr 1000 Washington Street • Suite 710 143053 :. 'L ' 06/13/2026 Boston, MA 02118 TIMOTHY KEATING - .,t D/B/A KEATING CONSTRUCTIOft - ~; TIMOTHY B. KEATING h'i? '� ' °in' 54 LOWER BROOK RD. b .. :.. ': : ttI f , ,.1 SO. YA R M O U TH, MA 02664 wolowavill=rmarromev rimermrloromirdemmonwpam oraramermarwaroasumerammamsioravafformsagiamov_._...,.. aswo.rno.................v.................... Undersecretary Not valid without signature