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Home My WebLink About0155 LAKESIDE DRIVE EAST tx 4 .. ,_.,.•....,. >, k .,,.,. .. .,, ¢ ,. r �.�,' .,. n..' 4 � r a,.rz L -�.�.y; ;;:��.: ..: ,A. ,3.... Y`�-��' �> w^. '�1; ��•; ;,�� ,...7»Y o- '.r, .•.,. ...,. :- ,.... N • :...,: ., ,,. �. r .1 L..:: Y U -':R.,. .'fi.w. k .. >s. �. ,. xd..., �. a _,. ,: r. H' ..Sy" �� ... �. 'm ,i: r r a. rr�• ik,ue,,�x a. �r �v$ :.�i :. ...: ..1 � C: ..'+� ,3 .. ..$,a�; .-., �.o. ;.. ,..,:, v :�.'"♦it_ ..,;. ,. 'L;� rd. 'g�f�'�-F"'"+�!'� �4� .r ,,c: p.;f�,.,. �w-•grls 4�.,�od ... -i.1i e+. ..., � ��s��.�...�.�.q �v.. ��.: ,.e: 1�.;�w�4': .:"^R."Vd ;:�r:. *i�� wvx:��.w i'..� �•�.. h ,�,.^.t 'S-s_'' ,`y}�s. �KI ..,I � ° ih W":� �i "� •'{/' R y .c$•6 ��°as5 n A n ° o P � 9 � y q ` P i v r r : O hY •� � � $ , 2 fY t , r A t L M 4 S o Town of Barnstable �Permit� Expires 6 months rom's date Regulatory ServicesMAM Fee 916,19. 1�' Thomas F.Geiler,Director � Nlld Building Division Q/21/3 Tom Perry,CBO, Building Commissioner i 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Val�ithout Red X-Press Imprint Map/parcel Number . Property Address _j SS Lti kt1Jj*aC o� Residential Value of Work$9TC( SS Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address _ 6 i ( 4 f ti'$it v n Contractor's Name s- /1 S Telephone Number SD,F 70 2 Home Improvement Contractor License#(if applicable) Email: --17,7 ��C �S �( j/�'Ftr►4`�,�o.r� Construction Supervisor's License#(if applicable) MWorkman's Compensation Insurance X-PRESS ER MIT Check one: ❑ I am a sole proprietor AUG - 1 2013 I am the Homeowner I have Worker's Compensation Insurance Insurance Company Name -SOWN OF BARNSTABLE . Workman's Comp.Policy# 6 ZZ L(N 3-�- Z-/U Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ® Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to4,��C-Jt7- ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *Where required: issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is requi ed. SIGNATURE: C:\Users\decollikWppData\Local\Microso8\Windows\Temporary Internet Files\ContenLOutlook\8R76BDVA\EXPRESS.doc Revised 061313 The Commonwealth of Massachusetts. _ Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers ADDlicant Information Please Print Legibly Name (Business/Organization/Individual): I I r, ke<♦"'i/ Address: S L( 0C cr r3wl-;_ City/State/Zip:Soy it �-/</euv t-4 mt. OW Phone #: 5,6- 7do-2 v Z_ Are you an employer? Check the appropriate box: Type of project(required): 1.8 I am a employer with 1 4. ❑ I am a general contractor and I 6. ❑New cons�,:ction employees (full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. [2 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.❑ Electrical repairs or additions 3.❑ 1 am a homeowner doing all work - officers have exercised their l l.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] j ai. i 5 W i M3"LIU vr'e hu V'iav 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. lContractors 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: LNA - Policy#or Self-ins. Lic.#: 622g1v3 7- 2-/® Expiration.Date: 34//z Job Site Address: rff L <kr,t'Jc 12r City/State/Zip: Ce"@?V'lte !ry/►I 02aZ 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 un to 1,500.00 anti/or one-year imprisonment;as well as civil nenalhes 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. 1 do hereby certify and r the pains and penalties of perjury that the information provided above is true and correct Sip-nature: Date: Phone#: _?1�6- 2.7('4— Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: r GT • snxrisrast.s. • MAM 16 9. A,� - Town of Barnstable Regulatory Services Thomas F.Geiler,Director Building Division Thomas Perry,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I, V< « N 4f` ers-c ^ ,as Owner of the subject property hereby authorize ��'f7�'�f ( 6I.F ifs'c pu'' to act on my behalf, in all matters relative to work authorized by this building permit application for: Al (Address of Job) Signature of Owner Date Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. C:\Users\decollik\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\8R76BDVA\EXPRESS.doc Revised 061313 � �1ze`fPo�nmaooac�ea/,C1a o��aaaca�tcoeC�.� . .Office of Consumer Affairs&Business�Regulation License or registration valid for individul use only ME IMPROVEMENT CONTRACTOR :! before the expiration date. If found return to: ` egistratlon: ' 143053 - Type: i Office of Consumer Affairs and Business Regulation xpiration x 6/14/2014. DBA ! 10 Park Plaza-Suite 5170 Boston,MA 02116 KEATING CONST. C � TIMOTHY KEATING i 54 LOWER BROOK RD g % SO.YARMOUTH, MA 02664 Undersecretary Not valid without signature i . I Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction SuperNisor Specialty +" � Lice nse:__CSSL-099351 ' TIM B.KEATING-` 54 Lower Brook Rd. South Yarmouth MA 02; e ..,i Expiration Commissioner 05/11/2014 a .. CERTIFICATE OF LIABILITY INSURANCE DATE,MM,,DD.fYYYYJ 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 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 oollcv�invl Let -_ -••..vPvv• If JVBRVI,a/q I IUN iS WAIVED, subject to isle 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 Schlegel 6 Schlegel Insurance Brokers Inc NAME: PHONE (AtC,No,Ea):34 MAIN STREET X(A/c,No): : PRODUC R West Yarmouth, MA 02673 CUSTOMER ID or -'--'--- INSURED — 'NSURER__ AFFORDING COVERAGE _-._.______....-. M___—___-...._... Timothy Keating Dba Keating Construction INsuRERACOLONY INSIIRANCE 54 Lower Brook Rd INSURER B CNA _-. INSURER C INSURER D: South Yarmouth, MA 02669 ----- -- INSURER E: - COVERAGES INSURER F; CERTIFICATE NUMBER: rH15 IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BEL D!M ^cViSivii iViiilnBER: INDICATED. NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF'�ANY E1CONTRACT OR I OTHER U DOCUMENT RED D ABOVE FOR THE POLICY PER100 CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE P RESPECT TO WHICH THIS EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. �iDDL'SDHRT-__.--. _ [ILR TYPE OF INSURANCE I INSR I WVD I POLICY NUMBER POLICY - n GENERAL LIABILITY I (MM/DDMYYY) (MM/DD!YYYY) I LIMITS L3594908 ^GO 000 C' 03 207'03/10/2C EACH OCCURRENCE' /10/ 13; ;.1,V X CUMb1tP lAL NCRAL LIAeIL'TY 70-REN �6.— =--_----- 03/10/201303/10/2014 PREMISES(Ea oaunerce: S 10,0,000 A IMS N. Dc —__- : ! MED EY.P(Anv one pwso 5 000 P=R e 000 S NAL&AD'✓IN JURY , c-1, 000, i r-- A I ! i Gtfm=HAL AGGREGATE S z,UUU,UUU GEn L AGGREGATE LIMIT APPLIES PER _ PG'LiCy C•M F.4:_---_PRO. PRODUCTS ^r o;0 :G s2,000 OOO -- I ;JeCi I I Lam' i - � .i AUTOMOBILE LIABILITY i S COMBINED SINGLE LIMIT I ANY.:i;TO I (Ea acudeat) + g ALL OWNPD.;7ns Ii:_FIEJUL€b AUTOS- BODILY INJURY(Per accidern S I itiREb.AUT:^.S I PROPERrYDAMAGE .____._—..___._..._..___..-.—. 1— iPeracc:den!i I NON-OWNED ALTOS i UMBRELLA LIAB OCCUR EACH OCCURREN EXCESS LIAB c c I CLA!IASAIADE AGGREGATE c DEDUCTIBLE ! P.ETENTION -- g I B WORMERS COMPENSATIO _ N I g ...__.-_._.._ .. I n cw UTtK5'LIABILITY I_a— v iU3/09/201203/09/20131 X ! wos.A�u ANr PROPME70R,P+R'NEn+EiiE+' NE Y:N ! . ^^r _Ut r O�f!CER:MEMBER EXCLUDED I Y ;NIA /O / O1 /09/2014!aEACH------_.-- — ------...__.._ 03 9 2 303 E.L. .ACCIDENT (MaadalorV m NHI I j s 100,000 It,yes descnoe under ! ------._—...—._..--'-- EL DISEASE-EA.EMPLOYEE g 100,000 ! DESCRIPTION OF OPER,.AT:ONS v-gow I i E L.DISEASE-POLICY LIMIT I g 500,000 1 + I i I DESCRIPTION OF OPERATIONS:LOCATIONS,;VEHICLES(Ahach ACORD 1d1/,Additional Remarks Schedule,d spa ce ace is required)TIMOTHY ZEATING HAS ELECTED NOT TO BE COVERED ON HIS WORKERS COMPENSATION CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PRlNA irtme I I lf•-s• AU _ED REPRESENTA7FVE J ACORD 25(20091091 u 1938-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD