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HomeMy WebLinkAboutBDLX-26-414 application REC--EivED z Y� MAY 05 2026 r (5L.DX' -404 44,._ !ciescirowfbay . iirli% o '"- y, BUILDING DEPARTMENT Amo�mt ,,Gymiti- . v`,, -- -- __ EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 (508)/4-c.-- 398-2231 Ext. 1261 ' w ' ,_y/ �j �-7 CONSTRUCTION ADDRESS: I ct h 4`r d �� P. V`- Qt—a✓2 t 4 C6 /-7 OWNER: V 4 re 0< "L d 173 /elAME C PRESENT ADDRE (, R? k) � T � CONTRACTOR:N— Ae4Di7) S / 2_,C)l t>e/ l"/601) 0- yy"/?7o47 `ri �� NAME MAILING ADDRESS TEL# EMAIL: l ' ir1, P zt7:-'j 60 iej(. 7 't i t /0 1^-, _<e)k i 6V 2 7a- ,Residential ❑Commercial L Est.Cost of Construction$ C Z-) 56v Homeowner is Applicant? Yes No Home Improvement Contractor Lic.# 1 y 30 s3 Construction Supervisor Lic.# 15 .S) WORK TO BE PERFORMED 1 Tent Duration (Fire Retardant Certificate required) Wood Stove Siding: #of Squares // Replacement windows:# Replacement doors: # Roofing: #of Squares (,'6 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�6 I) Nit V I `/ 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. I understand that any false answer(s) will be just cause for denial or revocation of my licen and for prosecution under M.G.L.Ch.268,Section I I. �� x Applicant's Signature:_ C Date: I c y Owners Signature(or attachment) Date: Approved By: Date: Building Official(or designee) Rev 6/24 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Lafayette City Center J 2 Avenue de Boston,Lafayette, MA 02111-1750 r <•' www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(BusinesdOr /gaoizatio»/Individual): �t✓t ^��fr/15 Address: s 1 1-O ln1 P/ rad JI-' Pe Ci /State/Zi : 4/'/1-1 8J� I'll d? , Phone#: S t 7 b(d ?71? Are you an employer.Check the appropriate box: Type of project(required): 1.21 I am a employer with / 4. ❑I am a general contractor and I employees(full and/or part-time).' have hired the sub-contractors 6. 0 New construction 2.❑I am a sole proprietor or partner- listed on the attached sheet. 7. a Remodeling ship and have no employees These sub-contractors have 8. 0 Demolition workingfor me in an aci employees and have workers' Y capacity. 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.]f c.152,§1(4),and we have no employees.[No workers' 13.1:Other 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 are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors 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 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 /,/4- Policy#or Self-ins.Lic.#: 6(( S 5`1 0 QD 2??11A/.372Z g Expiration Date: 3r11' Z 2 Job Site Address: t "/ C n4�fee'6-re-7, le City/State/Zip:u y4rMo5j fit/?02673 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. Signature: Date: `( Phone#: SO 7-6O 77OZ 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): 10Board of Health 20 Building Department 30City/TownClerk 4JJ Electrical Inspector 5E/Plumbing Inspector 61:Other Contact Person: Phone#: Keating Construction _ Home improvement contractor registration: DATE April 27, 2026 Quotation # 1 54 Lower Brook Rd So. Yarirtouth MA 02664 Phone (508) 760 2702 timkeatind660hotmail.com Proposal for: Job name! location: Jake Diauto Same 19 Chandler Grey Rd West Yarmouth Ma 02673 We hearty submit specificatons and Description Strip roof shingles off entire house Install Certainteed water and ice shield on lower edges,valleys and chimney Install new vent pipe flanges, and 30 lb tar paper on decking Install new white drip edge Install Certainteed Landnr-ark 30 yr architectural shingles Install Certainteed Hip and Ridge cap AB debris and trash will be removed and disposed of properly t. 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: $12,500.00 Senior Citizens discount included 1/3 payment due at start of job a d remainder upon completion Acceptance of Proposal: L 2 .6 pDate of acceptance. � C Acceptance of Proposal. 1✓ Date of acceptance:,) ,7 0 The above prices, sp ifications and conditions are satisfactory and are hereby accepted. THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Individual Registration: 143053 TIMOTHY KEATING Expiration: 06/13/2026 D/B/A KEATING CONSTRUCTION 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 expiration riatg if found return tn• HuiviEiivirrivvEMENTCONTRACTOR •-r••---•- - 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 cY 54 LOWER BROOK RD. 71 SO.YARMOUTH, MA 02664 Undersecretary Not valid without signature - Commonwealth of Massachusetts Construction Supervisor Specialty Division of Occupational Licensure Board of Building Regulations and Standards Restricted to: Construct• 1i' �Specialty CSSL-RF-Roofing CSSL-WS-Windows and Siding CSSL-099351 z rcpires:05/11/2026 11M B KEAT191G "' 54 LOWER BROOK ROAD p SOUTH YARIE )UTH MA 02664 2 bJ 1 407,(,y3i Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. Commissioner \ r ew r,s_ Contact OPSI:(617)727-3200 or visit www.mass.govldpllopsi znbrrrt,sareM:•.rt1rswnommo3 ewtnsoiJ tbood,::p•�o0 to noieiviO ct aYasbnste bnn roc:...;'rig,ft gnib!iu8 to bib09 ,r-ti.,rr ,n 23cigx3 x rateeo-J22D rt 3t1 i3&i? v+. tN"R' )c .A3W04 r-d ti ..4 "i. .:,. isnoiaairnmo3 DATE(M MID D/YYYY) A(7C- RL CERTIFICATE OF LIABILITY INSURANCE 04/06/26 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 NAAME: PAUL SCHLEGEL WORLD INSURANCE ASSOCIATES LLC A/PHONE ,Ext): 508-771-8381 FAX No): 508-771-0663 34 Main Street E-MAIL West Yarmouth, MA 02673 ADDRESS: schlegelinsurance@gmail.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: TRISURASPECIALTY INSURED INSURER B: CONTINENTAL CASUALTY TIMOTHY KEATING DBA KEATING INSURER C: CONSTRUCTION 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. NSR ADDL SUBR POLICY EFF POLICY EXP TYPE OF INSURANCE LTR INSD WVD POLICY NUMBER (MM/DD/YYYY) (MMIDD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR DAMAGE PREMISES ( RENTED occurrence) $ 500,000 MED EXP(Any one person) $ 10,000 A NRG-DBG-1647180-001 03/19/26 03/19/27 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY __ AUTOS HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE , ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000 B OFFICER/MEMBER EXCLUDED? N N/A 6S59UB0224N37226 03/09/26 03/09/27 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional 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 BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN TOWN OF YARMOUTH ACCORDANCE WITH THE POLICY PROVISIONS. BUILDING DEPARTMENT YARMOUTH MA AUTHORIZED REPRE NTAT• 7 ©1988-2 15 AC RD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD