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HomeMy WebLinkAboutBLDX-26-676 applicaiton ,�� E C i Office Use Only S,tea 3 2025 t�ermitMo i3 wild U N 2 I Amount'S7.7 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 7 Z (4p-f--G; n ,, 1 Q4,( '2 LArni4J/. 0 Z‘6 OWNER: £ 4f1/r 11/1 f lito4 7Z (4p 'i>, Ace,-, d''2 V4/44v,,h- NAME PRESENT ADDRESS TEL. # CONTRACTOR: ifra N1E Pt k 4 fi Pr y'MAILING ADDRESSf o)� 0/AlcialTEL.#� EMAIL: (( k Ii,1l ( 2/ Allot i4Act /,( )/'1 l� &V VA Residential 0 Commercial L Est.Cost of Construction$ l(/2.5.U Homeowner is Applicant? Yes No J Home Improvement Contractor Lic.# 1(13 Of] Construction Supervisor Lie.# 9 5/ WORK TO BE PERFORMED 1 Tent Duration (Fire Retardant Certificate required) Wood Stove Siding: #of Squares 5 Replacement windows:# Replacement doors: # Roofing: #of Squares 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: Y4 l r4 Cal* NI 7 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 revocati of my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: i ' V n—v--- — Date: fez/ Z-f Owners Signature(or attachment) Date: Approved By: Date: Building Official(or designee) Rev 6R4 The Commonwealth of Massachusetts Department of/ndustrialAccidents 9 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):Wry/ kle,417,15 Address: .SI/ 1-Olv et- Qtod!/tt() City/State/Zip: (fen o)1-6 A 0264 Phone#: SOS' 76O 27&,;' Are you an employer?Check the appropriate box: ,--/iii 4. I ant a general contractor and I Type of project(required): IJ 1. I am a employer with / ❑ employees(full and/or part-time).' have hired the sub-contractors 6. ❑New construction listed on the attached sheet. 7. Remodeling 2.❑I am a sole proprietor or partner- ship and have no employees These 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 10.0 Electrical repairs or additions 3.❑I am a homeowner doing all work officers have exercised their 11.1=1 Plumbing repairs or additions myself.[No workers' right of exemption per MGL y� comp. 12.0 Roof repairs insurance required.]* 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. tConttactors 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. 1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#:(S s S U Q O 22,t44,37 2Z( Expiration Date: -3/5/22 Job Site Address: 7 2 ('lt 4-� �,fei, /� - City/State/Zip: y/,ia,fG 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi and the pains and penalties of perjury that the information provided above is true and correct Si afar: Date/22/ 2/ Phone#:so1" 74(0 7OZ, Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(check one): 10Board of Health 20 Building Department 30City/l'own Clerk 4.1:1 Electrical Inspector 5E1'lumhing Inspector 6.❑Other Contact Person: Phone#: Keating Construction Home improve Ment contractor +eg,stratEon 143053 DA'T June 15, 202$ 54 Lower B�� Rd Quotation M t So Yaruth MA Ph°ne (508) 760 2702 tIrniteatinQt 6c hotma0-.9111 Proposal for: Came Haskel Job name( location: 72 Captain Bacon Rd Same Yarmouth Ma 02664 508 631 9084 W• submit specifie.stons and Strip stelewall of back side walls entire Install Typar house wrap and new cornerboards with Azek as needed Install new Azek window trim and Azek sills on all windows Install western red cedar clapboard Remove gutter,facia and soffit Install Azek facia and soffit Re hang gutter All debris and trash wilt 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 labor for the sum of. 111A 1 4 1134 ra v Lk > " a F° h n• ak 1 �-`. 3����.i, z � ,.'.4. �r.yi �^tix�7�i tiT >, d5}j'•A `"y Pa` -,: :.. �.- :ea!•: c �,. z,.4: .rut` , iM�Y. �'`. �'*'t {1 f. '. Balance _ � due upon > :a 3- /.. �+•er '. Gtx9v i.• �T,vr .,�Y,k' j,',1' bF,, Y �k.. .# afMP<xr fY 4°i 5 po n� x z r : � , � � F �.� �. t Acceptance of Proposal: Acceptance of Proposal: Date of acceptance: b Z 2.e Date of acceptance: The above prices, specifications and Condit ions are satisfactory and are hereby accepted w ate, !,, �•,.,;. «y 1 ��fA h �� 4� •�., orb.y • faC =�6Mn �,l^k.of 4 it6'Siij aY "ettx 7 s, ACOREP CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDMYY) 04106/26 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: N 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 NAMEACr PAUL SCHLEGEL WORLD INSURANCE ASSOCIATES LLC �P�pH�ON .Enl: 508-771-8381 I jac,Not: 508-771-0663 34 Main Street EJAAIL West Yarmouth,MA 02673 ADDREss: schlegelinsurance@gmail.com INSURER(S)AFFORDING COVERAGE NAIL a INSURER A:TRISURASPECIALTY INSURED INSURERS: CONTINENTAL CASUALTY TIMOTHY KEATING DBA KEATING INSURER C CONSTRUCTION INSURER D 54 LOWER BROOK RD 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. INR TYPE OF INSURANCE ADOLSUBR POLICY EFF POLICY EXP INSD WVD POLICY NUMBER (MMIDD/YYYY) (MMIDONYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE El OCCUR DAMAGE EM SES(EaLoccu ence) -PR $ 500,000 MED EXP(Any one person) $ 10,000 A NRG-DBG-1647180-001 03/19/26 03/19/27 PERSONAL S ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY Dm Ei LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINEDtSNGLE LIMIT $ accide ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY _AUTOS ONLY (Per accident) $ $ UMBRELLA LIAB _OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE DED I I RETENTION$ $ WORKERS COMPENSATION I STATUTE I I ERH AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE B OFFICER/MEMBER EXCLUDED', N❑N/A 6S59UB0224N37226 03/09/26 03/09/27 E.L.EACH ACCIDENT $ 100,000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE$ 100,000 I/yyes,Oescnbe u�MerOF O DESCRIPTON PERATIONS below E.L.DISEASE-POLICY LIMB $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached H more spew I.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 AUTHQ[tIZED REP NTATIyf ©1988-2015 AC D-CORPORATION.All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD -4 Home Improvement Contractor Registration Card Registration valid for use type,only before the expiration date. Type: Individual Number: 143053 Expiration: 06/14/2028 Issued to: w Keating Construction (19 ,+ TIMOTHY KEATING 4,.. tim B keating 54 LOWER BROOK RD. �Q SO. YARMOUTH, MA 02664 :-li8 &R.La- Office of Consumer Affairs&Business Regulation Layla R. D'Emitia 1 Federal St.,Suite 0720,Boston,MA 02110-2012 Undersecretary 6/23/26,9:16 AM Details Licensee Details Demographic Information u1T Name: TimothyB Keating ner Name: License Address Information ipcLato ity: South Yarmouth e:d MA e:: 02664 ountry United States License Information License No: CSSL-099351 License Type: CSSL-RF-Roofing Profession: Building Licenses Date of Last Renewal: 5/1/2026 'Issue Date: 6/4/2008 Expiration Date: 5/11/2028 ;License Status: Active Today's Date: 6/23/20265/14/2026 Secondary License Type: !Doing Business As: Status Change Reason: License Renewal Prerequisite Information Licensee: Keating,Timothy B Relationship: Attribute Of License No: CSSL-099351 No Available Documents I I 1 file:///C:/UsersMm/Desktop/26 w/CSL 26.html 1/1 _� -___- -_ ' _ ___-_� __ ` . .� ` ,� � �i��'� � . � .� ."..a*`'*,.~ - "`� ,,x ^ `. �` .^� � ~~' , �` - � , ../"^"^*/°~.^' . ^°.-�� '^ '"` '`` . +' ' � `` �� .�� ` � ~ ~ �'..' `.,�` � " ..`� . .. �~� .. `. � ` . `�. ~. � '� �- '� ^.�' `'/ � � ~ , ^� .'^/ ` / ` . �����w a* `.w., , ' -",°.m ` ^ ~ '/ '�� ., '` ' `� ' ` � v � ° '�^�omm"`' °°° � ' .