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HomeMy WebLinkAboutBLDX-25-1338 • _ / Of YI4 ,. Office Use Only c p t, . it9 ' r�` P k Permit#Y' +'S()3� y OCT Amount q 4,MI.TiAC�� gy NG I)EFA1-7 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 / �` (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: I kt= 2. 0/0 r " 14-Nl/1 si- VcrAioJh Ad OWNER: C 4 /! 4 5 I 1 G( Ir 6,-. 162 t/(12 1414 n J/ V 71.0 0--1)/z lilt NAME `� PRESENT ADDRESS J! / ,,,TEL. it CONTRACTOR: k 0 f Sy LGel gra4 le l/4 % Ili— // NA17I J_ MAILING ADDRESS TEL.#t s O L 7 aU e7ez EMAIL: . J W9 /l e4�>i, ho`f c/ .CUB O Residential ❑Commercial I_ Est.Cost of Construction$ '5C.) � Homeowner is Applicant? Yes No "/ Home Improvement Contractor Lic.# 1 Li 305J Construction Supervisor Lic.# l SS / WORK TO BE PERFORMED i ., Tent Duration (Fire Retardant Certificate required) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares 7 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: Yaw/ 01) t"' 6' ' 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 revo n of my license and for prosecution under M.G.L.Ch.268,Section I. Applicant's Signature: Date: l41.7/ ?S' Owners Signature(or attachment) r Date: Approved By: Date: Building Official(or designee) Rev 6/24 • rfy oisia.: r.. I he Commonwealth of-Massachusetts .N Department of industrial Accidents '4-1. :1 i9 ,,. Office of investigations ,., :a qt C _i �,,�/; Lafayette C ty Center 14' W 2 Avenue de Lafayette, Boston, MA 02111-1750 �--`;�,4 www.mass.g ov/dl a Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): f ityi Kia4t7 4 t : eI3' - P Andress. �' ��� City/State/Zip: tiialo,) lim VvVI Phone #: 7d 0 2 ) ° e Are you an employe ? Check the appropriate box: • Type of project (required): i I . M i am a employer with 4. ❑ I am a general contractor and I ' , �t,.�,^t• I employees (full and/or part-time).* have hired the sub-contractors 6. D 1Vei construction listed on the attached sheet. [4 R e�model i ng 2. El I am a sole proprietor or partner- I ship and have no employees These sub-contractors have 8. ❑ Demolition I working for me in anycapacity, employees and have workers' r r 9. 0 Building addition [No workers' comp. insurance comp_ insurance.: required.]e .] 5. fl ts 10.n Electrical repairs or additions We are a corporation and i 3. ElI 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 Other employees. [No 4 o workers' I .❑ Othe. comp. insurance required.] *Any applicant that checks box #1 must also till out the section below showing their workers' compensation policy information. Homeowners who submit this affidavit indicating they arc 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. It 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 A/.A Policy # or Self-ins. Lie. #: L�� (571 Expiration Date: 3 / /z ' Job Site Address: 61 01 0 fir ,il gfr City/State/Zip:_ A/'4/1O ,ñZ.. i4i4(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 uP tler the p ins and penalties of perjury that the information provided above is true and correct Sianature. Date: Phone #: 5-0 7� O 2 , ® 2 Il Official i � I use only. Do not write in this area, to be completed by city or town official.al. I il II City or Town: Permit/License # 11 I Issuing Authority (check one): II it 1 D Board of Health 20 Building Department 3 f City/Town Clerk 4.0 Electrical Inspector 5E:Plumbing ,1 lIIInspector 6.DOther lContactPhone 1I: i Person: 11 Keating Construction Home improvement contractor registration: DATE August 20, 2025 143053 Quotation# 1 54 Lower Brook Rd So. Yarmouth MA Phone (508)760 2702 timkeating66 a(�hotmail.com Proposal for: Job name/location: Carla Sharrow Same 162 Old Main St Yarmouth Ma 02664 We hearby submit specificatons and Strip wood roof shingles off back lower roofs only Install Certainteed ice +water shield on all lower edges 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 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. We propose hereby to furnish materials and tabor for the sum of$6,950.00 113 balance due at start of job Acceptance of Proposal:Ce2- (--- Date of acceptance: /J I' ! Z d Acceptance of Proposal: Date of acceptance: The above prices, specifications and conditions are satisfactory and are hereby accepted. Ire ''.121103 al!m .7.r) Ulf , . . 11114. igCommonwealth of Massachusetts Construction Supervisor Specialty Division of Occupational Licensure Board of Building R!e�gulations and Standards c�sstr;ct..rt tc: Hia�AAJ a^A. .^^a.aa.. ay. Constructi� up lr Specialty 4e C5SL-W5 - windows ana ,ia:ng CSSL-099351 4►' k' expires: 05/11/2026 TIM B KEATI4O T 5.44 LOWER O D?OK ROAD 1 r _ Suui r �rAR UiTti IVIA U2b64 :' LO .. !UIlv/l G I/ E./aa7 sGa'!J Ct at:!-mat Gt 2I&IVI t VI •t 1[i II G/JJU -I�1.I) i4(J l#1Cd&G r Bui! 1IiI '`ode*. is cause for revocation; of this license. i�i.a ii it ti- Code 4tt Commissioner f Contact OPSI: (617) 727-3200 or visit www.mass.govfdplfopsi 1 +'rr lti to Mlsawnommo3 Icnoftquoa0 to noleiviO „ h b 171;ar.. `I,Oe,sAJ'���Qnibllua to elope✓)1s,J:.;,rre'4lvgUcl tountvfO7 dS4S'.t;lco reee o•J22J • tsnmealmmo9 THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs and Business Regulation 1000 Washington Street -- Suite 710 Boston , Massachusetts 02118 Home Improvement Contractor Registration : == , —7. t Type: Individual .f,• egistrai:ian: 14;3C�5:3 TIMOTHY KEATING : a D/i• 3,A KI :,ATI(�JG CONSTRUCTION ` � . . . Exi�ir,�tion. 06/13/2026 0 54 LOWER BROOK RD. , - . 4 . .. ._...... ._...... _��..._�.�.�__. ..�..��..... .,._ SC). YARMOUTH. MA 02664 : c!. , 4 cil,\N ,..4 .,.., 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 Reillgritign Emairitign 1000 Washington Street - Suite 710 143053 Ai 06/13/2026 Boston, MA 02118 TIMOTHY KEATING , ( w , ri DiE3/A KEATING CONSTRUC IOf :; , '4,,,,,4?„ :=„, ivi I r-:,:,7. el- , TIMOTHY B. KEATING :t` ° `,%, s-�: tir, ' ,q io. bt dm._ 54 LOWER BROOK RD. 'w wu.oa `. -'. ,41/ ulik v SCE. YARMOUTH, MA 02664; `" A A Undersecretary Not valid without signature ®=� s IMOTHYK01 AREGULA Ate.' ). I DATE(MM/DO/YYYY) _ _.r— CERTIFICATE OF LIABILITY INSURANCE I 8111/7415 THIS CERTIFICATE 3 IS3u D A3 A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS ^"^"' NEGATIVELY AMEND EXTEND OR ALTER THE COVERAGE AFFORDED RY THE P1i.ICIES 3E¢FTIFIr,n r F r - Nor .. �.R,.r.xTIVEi_`i (?R rnra r 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(iesj 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 a .3 :.::.-L$. Y`7:'i.,"s rS.-a�ii-aa:s-isstia. w.:.::.-..:,..:,:.::,.,•lid 749.Lt-.17:.i� L"'5zp$,61k4"-g.'Yj. PRODUCER CONTACTNAME: ui...+.r r11t1:Z f' A .,.- .r.. n++rwe --tea• cAY s--es - -T� i 34 Main St. (Aft,No,Etct):t:ri3ol i i$+ti3b N (A/C,Ivo):taUsaj 7714 663 'West Yarmouth,MA 02673 iREss: INSURERS)AFFORDING COVERAGE NAUC• -_-_-- IISl1TtER A:Nautilus Insurance Company --- 17370 INSURED INSURER B:Continentat Casualty Company 20443 . TIMOTHY KEATING OBA KEATING CONST INSURERc: 54 LOWER BROOK RD INSURER 0: SOUTH YARMOUTH,MA 02664 INSURER E: INSURER E 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 ISSI IED 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. _ INS` ADDL,SUBR. POUCY EFF POLICY EXP I Lilt TYPE OF INSURANCE NNSD1 WYE) POLICY NUMBER (MIWOThYY'r I t [MMI .,-i,Y), LBWS A X COMMERCIAL GENERAL LIABILITY1,000,000 1 EACH OCCURRENCE E I CLAIMS-MADE ) X I OCCUR NN1675006 311912024. 3:1912025 ! ) i DAMAGSES(EE TOa RENT 50,000 PREIA! o^^ED I MED EXP(Any one person) 1$ 5,000 IPERSONAL&ADV INJURY I$ GEN'L AGGREGATE LIMIT APPLIES PER: i GENERAL AGGREGATE $ 2,000,000 POLICY LOC PRODUCTS-COMPA)PAR; $ 2,000,000 I OTHER: _ $ AUTOMOBILE ilA8I3rY (Ea accidentINED) SINGLE LIMIT $ ANY AUTO BODILY INJURY(Per person) 3 OWNED- 1 I SCHEDULED Atli OS ONLY AU tOS. BODILY INJURY(l'er seeWent) $ H RF�pp 1 NON-OWNED I PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY I(Per accIdenn $ I UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS L_AE CLAIMS-MADE i AGGREGATE 3 OED I I REIENI ION$ $ B WOP.I(Et<S COMPEHSA.TION l X PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE YIN 0224N372 3/9/2025 3/9/2026 EL EACH ACCIDENT $ 100,000 OFFICER/MEMBERFXCIIJEFFD% I N I NIA Y ie NH) EL DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below El.DISEASE-POLICY LIMIT $ 500,000 i I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule.may be attached If more space is reaufrod lIN sURANCE COVERAGE IS I IMITE. Tn THE TERMS,CONDIT DNS,EXCLUSIONS,OTHER I IMirATVIN,_AND ENrrIRSEMENT OF THE cnL!CY ( CERTIFICATE HOl DF_R CANCELLATION I SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Cate SV G'cry THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 2235(yannough RD West Barnstable,MA 02668 I AUTHORIZED REPRESENTATIVE ACORD 25(2016103) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD