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HomeMy WebLinkAboutBLDX-26-721 application ;ogY9;�_. RECEIVED ' Office Use Only 0 Perna/6uPX"a6 �_."' - , JUL 0 2 2026 Amounts�� .,,. . oUIL my�'A'u EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext.111261 V4( i CONSTRUCTION ADDRESS: I Z L-0 LA.) v cfGO Ii 0 -( PA- OWNER: ?C,1 v 1 (' 55 c 12 Z-oQ I c - &fool-- P Y41vt1v 7 i ,.z' NAME PRESENT ADDRESS r TEL. a t CONTRACTOR: l,Vi ( c +i t) ,s-� Z.-6 W� I�G�` I NAME VIAILPNG ADDRESS /414-o& F TEL-4_cos- 7(0 2 2 er 2 • EMAIL: I i An f'Pc,f/r 1 p 61-V�) (404 t'ttkt< ((Out" U Residential 0 Commercial L Est.Cost of Construction$ t() COO Homeowner is Applicant? Yes No J Home Improvement Contractor Lic.# / i 30S 7 Construction Supervisor Lic.# €t 13S WORK TO BE PERFORMED ,:i Tent Duration (Fire Retardant Certificate required) Wood Stove Siding: #of Squares 1 ic 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: y(1/M tU/v7 ((( 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. I understand that any false answers) will be just cause for denial or r atio of my license and for prosecution under M.G.L.Ch.268,Section I I. l Applicant's Signature: ( �i 7/Date: L / Z-C 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 p Lafayette City Center 1 , ^, f 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): r14 Address: 5y City/State/Zip: G7 1 vJ Y "U OZ46' Phone#: $ c 7'0 270z Are you an employer?Check the appropriate box: Type of project(required): 1.E 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. El New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. Ur 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 Y 12.0 Roof repairs insurance required.] ' c. 152, §1(4),and we have no employees. [No workers' 13.❑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. 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: CA/4 Policy#or Self-ins. Lic.#: 65 S U 6 O ZZ i,yJ?22 e Expiration Date: 31 S( Z 2 Job Site Address: / 2 !'W g/22 t t C City/State/Zip: YWn'l/Ao l 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 the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: r l Z! Z� Phone#: 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 211 Building Department 3❑City/Town Clerk 4.11 Electrical Inspector 5EIPlumbing Inspector 6.DOther Contact Person: Phone#: AC:()REP CERTIFICATE OF LIABILITY INSURANCE DATE oao6/zDs 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 NAMEACT PAUL SCHLEGEL WORLD INSURANCE ASSOCIATES LLC (PnN/CO,!„NE Ertl. 508-771-8381 I IC,No): 508-771-0663 34 Main Street EMAIL West Yarmouth,MA 02673 ADOREss: schlegelinsurance@gmall.com INSURER(S)AFFORDING COVERAGE NAIL A INSURER A: TRISURASPECIALTY INSURED INSURER B: CONTINENTAL CASUALTY TIMOTHY KEATING DBA KEATING INSURER C: CONSTRUCTION 54 LOWER BROOK RD INSURER 0: 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. TNSR APOLBUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INS°MD POLICY NUMBER (MMUDDIYYVY) (1/101R10/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE E 1,000,000 ❑X OCCUR PREMIESORENrED CLAIMS-MADE DAEAGES(Ea occurrence) E 500,000 MCD EXP(Any one person) $ 10,000 A NRG-DBG-1647180-001 03/19/26 03/19/27 PERSONALSADV INJURY $ 1,000,000 GENT AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $ 2,000,000 POLICY JET LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: AUTOMOBILE LIABILITY COMBINEDt SINGLE LIMIT $ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) E AUTOS ONLYP AUTOS (Per accident)TY UMBRELLA DAMAGE AUTOS ONLY AUTOS0NLV $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE S DED I I RETENTIONS $ WORKERS COMPENSATION STATUTE I I ER AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E .EACH ACCIDENT $ 100,000 B OFFICER/MEMBER EXCLUDED? N❑ .L N/A 6S59UB0224N37226 03/09/26 03/09/27 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE I 100,000 Ilyes describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space le 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 AUTHO(IQED REIHWIS TATIye.�.I ©1988--2015 AC O tDCORPORATION.All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Keating Construction DATE March 26, 2026 Horne improvement contractor registration' 143053 (quotation 0 54 Lower Brook Rd So. Yarmouth MA 02664 Phone (508) 760 2702 ti± eating€6P�. _.� Job name/ location: Proposal for: Same: __ Paul Beggs 12 Lower brook Rd Yarmouth Ma We hea • submit s• -cificatons end ..-,_ - r._ Description _.. :_ Strip roof shingles off entire house Install Certainteed water and ice shield on lower edges and chimneys Install new vent pipe flanges,bathroom vent and 30 lb tar paper on decking Install new white 8 inch drip edge Install Certainteed Landmark 30 yr architectural shingles Install ridge vent at all peaks Remove all rake boards and install Azek trim boards • 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. $35.0() 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: $11,500.00 Senior Citizens discount included 113 payment due at start of Job and remainder upon completion Acceptance of Proposal: �'✓ Date of acceptance: 6 )29 /2-/ • Acceptance of Proposal: Date of acceptance:• The above prices, specifications and conditions are satisfactory and are hereby acc epted. • 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: * • Keating Construction • TIMOTHY KEATING .,, tim B keating 54 LOWER BROOK RD. ltt�� SO.YARMOUTH,MA 02664 �1 Office of Consumer Affairs&Business Regulation Layla R.D'Emilia 1 Federal St.,Suite 0720,Boston,MA 02110-2012 Undersecretary 7/2/26,8:45 AM Details Licensee Details Demographic Information ;Full Name: Timothy B Keating Owner Name: License Address Information City: South Yarmouth State: MA Zipcode: 02664 Country: 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: 7/2/20265/14/2026 Secondary License Type: Doing Business As: :Status Change Reason: License Renewal Prerequisite Information Pcensee: Keating,Timothy B Relationship: Attribute Of License No: CSSL-099351 No Available Documents file:///C:/Users/m/Desktop/26 w/CSL 26.html 1/1