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HomeMy WebLinkAboutBLDX-26-955 applicaiton i' L. 61 L. A &; G Li i 01'14ir ''�Qa�. AUG 2 2026 � ( 1` 4Permitit X_'o O—G 5, 0 , iie BUI ING DEf- :?2 ,A V f ,Y ,", c3y i . I Apt '�� y'G.ORATE0�1f. EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508)398-2231 Ext. 1261 dd CONSTRUCTION ADDRESS: ,> C ,c I e4 '1 e4 y v PO � For Mn6 2 6teJ F OWNER: " 1 0 ; r it I'✓ S 144-k ee v4/� v,�tc pe(4- - 02eci r NAME PRESENT ADDRESS TEL. k CONTRACTOR: -'1'./t gil '` C fit i / 5 ,t-i2vv 2 t Y4,- �[� 7t�O 2 7lJZ , 02��. NAME MAILING ADDRESS TEL. EMAIL: L t Gf62.(1 t 04 •." )ziQ t-f)-76 r ( • 6 0"7 dResidential 0 Commercial 0 L Est.Cost of Construction$ 101 S O Homeowner is Applicant? Yes No •./f Home Improvement Contractor Lic.# i f 30S3 Construction Supervisor Lie.# ?�'3s/ WORK TO BE PERFORMED fl Tent Duration (Fire Retardant Certificate required) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # v.'itom I'r i-,'ill e ( bve9 Ito, Roofing: #of Squares 0Insulation 6/`47 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: VW.M 04)414 V ' Loudon of Facility t 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 license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: �g1� 5'Date: 20/d r Owners Sigwatare(or attachment) Date: Approved By: Dale: Building Official(or designee) Rev 6/24 The Commonwealth of Massachusetts Department of Industrial Accidents =1: ';° Office of Investigations �= I Lafayette City Center 2 Avenue de Lafayette,Boston,MA 02111-1750 www.mass.gov/dia Wos km a'Compensation Im u,auaw.Affidavit BnilderalContractors/Etrtt,idans/Plumbers Applicant Information Please Print Let3ibly Name(Business/Organization/Individual): NJ/1/. 'c't i l� Address: 5C( L-g u,e e Q'cy p f' City/State/Zip: TMaJ 4,4 02Y Phone#: SOg— 760 2?0 Are you an employer?Check the appropriate box: Type of project(required): 1.(t I am a employer with / 4.L]I am a general contractor and 1 employees(full and/or part-time).* have hired the sub-contractors 6. Q New construction 2.❑I am a sole prtrptiraa,or partner- listed on the attached sheet. 7. Remodeling ship and have no employees These sub-contractors have 8. 0 Demolition working for me m any capacity. employees and have workers' 9. ❑Building addition [No workers'comp.insurance comp.insurance.: ram.] S-0 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.]t c.152,§1(4),and we have no 13.L]Other employees.{No workers' comp.insurance required.] 'Any applicant that checks box a1 must also fill out the section below showing their workers compensation policy infomution. 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 thatcheck this box must attached au additional sheet slowing the name of the sub-conntnctors and state whether or not those entities have employees.If the sub-contractors have employees,they must provide their Workers'comp.policy number. 7 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 59v60Z2M .37Z24( Expiration Date: 5/f/r2,p � /' Job Site Address: S C/d(i Q� City/State/Zip: VCLjd// v t�iJ Q' �/ V Attach a copy of the workers'coaupeasatioa policy declaration page(showing the policy*timber 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 itnpr:s ,.rw nt 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 ittatuano coverage verification. 1 do hereby cemifv an tlr pains and penalties of perjury that the information provided above is true and correct. Signature: \ Dale: S—//2ci(/c Phone#: -°( X U 2 70 2— 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): IDBoard of Health 2DBullding Department 3iCity/Town Clerk 4.❑Electrical Inspector 5L1Plumbing Inspector 6.0Other Contact Person: Phone#: AC=-C)RO CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) �-- 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 CONIACr NAME: PAUL SCHLEGEL WORLD INSURANCE ASSOCIATES LLC PHONE 508-771-8381 FAx IA/C.No,Eat):34 Main Street E-MAIL (A/C,No): 508-771-0663 West Yarmouth,MA 02673 ADDRESS: schlegelinsurance@gmail.com INSURER(S)AFFORDING COVERAGE NAIC U INSURER A: TRISURASPECIALTY INSURED INSURER B: 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. LTR TYPE OF INSURANCE ADULByUHR Bp POLICY NUMBER POLICY EFF POLICY EXP (MM/DDIYYYY) (MM!DDIYYYY) UMITS X COMMERCIAL GENERAL LIABILITY I EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE I X OCCUR DAMAGE-TO REN i EL) PREMISES(Ea occurrence) $ 500,000 MED EXP(Any one person) $ 10,000 A NRG-OBG-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 JECOT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER. $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) 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 $ DEDT 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 1 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 I � / ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD • Keating Construction DATE June 22, 2026 Home improvement contractor 'e9istrat1on 143053 Quotation # , 54 Lower Brook R 02664 So Yarmouth MA Phone (508) 760 2702 timke+a Job name/ location. proposal for Same Bill Obrien 5 Clark Rd Yarmouth Port Ma 02675 �+f; s. - tficatons and We Descript ~ : ` Strip roof shingles off entire house Install Certaiinteed water and ice shield on lower edges and chimney Install new vent pipe flanges. and 30 lb tar paper on decking Install new white drip edge > z Install Certainteed Landmark 30 yr architectural shingles E-7 Lo install Certainteed Hip and Ridge cap _ SAAA ..5 --pe -cafious msrc-41c C()L ks -jam -7z) S7T5 CO44.A ss rc►.. :� P..11 oebrns 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 Rotten wood repair is not included in this proposal. $35 00 per hr + materials if needed tvlaterrais guaranteed by manufacturers Workmanship guaranteed by Keating Construction for 10 years. We propose hereby to furnish materials and labor for the sum of: $10,500•00 Senior Citizens discount included 113 payment Clue at start of job and remainder upon completion Acceptance of Proposal; V _�.: Date of acceptance: ' \/'-•" ''`". ` Acceptance of Proposal: Date of acceptance:_ The above prices: specifications and conditions are satisfactory and are hereby accepted 's p q /1,,..k. f 4t.. v ' to 4- t 1. 'rry ,S, �f e �..., 1 .Jit . 3 Details 7,23/264 1 i:37 AM Licensee Details • t}_`,,.,, �4.y-...++-a ba.�x'.+.�a*rv..+MRa�rv'w.'ae"'w.f o,.w..,.+w. /maa.'.,.<s*CtteM "^.�.*_ •,ri . e fa.M4+-- i.,...— ++vas*.• �r '+v,.F...'`... "•••*,..r..'r""•.r..n.w••.-.irow••..•...w... ..,.v.<+a.. I)�t t R t3 =r 1 t t '" ..r...r,.,.�...4. .,s�-4�-..,;.� --~.. '`��` w .A. ea Full Name: Owner ...., .,-�.W +it+^wa"Nte.'..�feys:.. Name: .W.HJa-f{+)?4c♦+MTry.`f.•V^'r>.r..•s..a....4.,�nMi:�.i_ ...�Y/r.+YA°1Y'�•:M Hi^31:!'N.IY�W�•�fNAV•(W If.i+ -•,,..lira...•.... LicenseAddress �. _..� pAyHl.M, TM/�W.�•�-yy.�,raaKd�aMA4 . fi a{it"f ..M Nh . 4iiHr .V._ : ?Hf1M..yr.y'.4nb .,N✓4^ MMtM1w.�t.w' MBM1.4W ➢Yo !-aMn w-aw.n.N.IrY...iia.rrw.nMribls.+..+i.►I..•!a+,*...wa .Nr�l.M . >Y .-- . rur ..1..1.11rw,L '� a ( a � rlN.Y�u !" �� ",.„/... MJM ., •,l.{,',,,,, ,,. ...Xlax.^f 4.Kf,.,/.^i'^iM .,..,.GM ,dd.blIY O -I4W Y'^tls'9.r✓4Mv..M -...4.''(..s.!y..,..,..... YmN+,,,,,,.'-M4..-,l.:fM•... ..sWsuttn, ..wYr.�h fM/ 4 .NMY.MVwq�LM.sw+ns+'iq. • MA State. 02664 Zi fie: United 1�`+i\+ rrw`rrr, 66..,, :srrn:•.:,r.,w ..:....,,,,.wi..i,.:/..,,.. .....:,..n.,,,,.•..N,.w.tr:.,..`.,.:r....»Y•u....,.t:....Wt......o.a-,..v....-?.ew. Awnt•a•.:,M-.v..:ra...;.„,y....n.w�+"^,.....,, un�1 Vr.. ,.... S._ r ..a n.- -.a,,,.w.s.-•��....+vra.+..t.as.+:W' [i w-sMtwwb.m.relvsa. .......r-.' ....>..s•--.....Y+..w..iM..+ew ..MVW.v.e..t ....wn....•e..,... w.or. u.. .w .w...., «M..M'+, s ...tee. ..44..,•.�.e'..,�.•-..w �.♦w• .f I jcensC tnfcorrittai �. . ....,. � - ..... .�. ....� ►4.f' �` q,AIN!Y•y.'h.4`t...''/..J.w.b.-.e.w.sw. - Type: M, y��. .- 4 License • 'Prateion: BuildingLicenses1'�i�C��� 4I 8 Expiration Date: 711 t 't 4� Issue Date:License Status: Active Today's Date: Secondary Uoense Type: 4 wing Business As. Sl,.,i amse Re t �� ..w.w.,w ,.....,.«..,.,»..w.-,.a..,w.w.w•�.x..�..,,.w�w.u...�..,.., ..�..w.tswns....,..w....w.,..., tatus Change Reason: F[ ;a ' t nfor E `ri ..,..."..,...,.., , ,:�....,..,,:).. ..m.......,.,, ......,,..... awYeM++.•♦+ +..+....s��M,-.-e. ..-.-«. ,.4/ . '. - 1. . .s.�".ea. �_ .r.,'........�.... .. .- ...._......_.........w_.....................,w..... .. s Licensee-. Keating. Timothy Relationship: At r u { License Nob Cat~.-t 5 • No Ava abe Documents Hone Improvement Contractor Registration Card Registration V811d for use type, only before the exptrrti n ei Type# tndIvidual ,..:Y. , tis ur r r: 143053 Expiration: 06/t4/2028 issued to• * il eating -onstruc ` TI MOTH Y K ATI Nirt tim B keating ,.4, : .. 7OWER 6OK RD. YARMC U H. MA 02664 i . office of Batt u Af1 r sit, s Regulation a l !l'tgIIcr federal _.. Suite 0720, auston, MA UZ 1 lU-2012 Undersecretary . , 4,... ,'.. t W t Y . • . , 14W- , , ,,,',1 . a i .. , (.. ` , O.. 1 .. ...,., ,.......... ., ........