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Home My WebLink AboutBLD-19-001350 '✓ 0 :1/1 C � ;PermiW 0 ids,SEA , �� S ,mmmt 6�.� Cr 1 Permit expires 180 days from = - issue date EXPRESS BUILDING PERMIT APPLICATIq� '�5p ON TOWN OF YARMOUTH Yarmouth Building Department RECEIVED 1146 Route 28 South Yarmouth,MA 02664 SEP 05 2018 . (508) 398-2231 Ext. 1261 1/ a Bull. . t : • ..T l CONSTRUCTION ADDRESS:__I Seit1II SA Ave YA/'Mosr14 ,s By: A r. / foo ASSESSOR'S INFORMATION: Iff . Map: Parcel: OWNER Su >e ether 7'ei//(ref ISI cei tr, Sc< ,4-,r ((cjnctiti la NAME / PRESENT ADDRESS 1/ TEL # CONTRACTOR I ( ,vt A e< (-,," iv 40,,G.- A kat- I, ye/tuck- NAME NAME MAILING RESS r TEL# SO a- 76o z y O`t CiResidential ❑Commercial Est Cost of Construction S i CDU o Home Improvement Contractor Lic.# 1 V is I> Construction Supervisor Lic.# sS 71/ Workman's Compensation Insurance: (check one) , ❑ I am the homeowner ❑ I am the sole proprietor i I have Worker's Compensation Insurancer , Insurance Company Name: ( �� Worker's Comp.Policy#61 oO 072 Y42'2 WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove • Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares 2 A ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. r( )Replacing like for like Pool fencing *The debris will be disposed of at `y Ge-MINyt"t / 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 answer(s) will be just cause for denial or rev. ation�Io�ff'my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: O ti /L. —e----,--- Date: ciii /it Owners Signature(or ttachment) Date: �y Approved By. ��" --7-'-' / �� Date: B >i;./:.dal(or designee) EMAIL • L:' SS: Zoning District Historical District ❑ Yes ❑ No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District Within 100 ft.of Wetlands: ' 0 Yes 0 No 0 Yes 0 No The Common wealth of Massachusetts �j1 Department ofIndustrial Accidents 1 Congress Street, Suite 100 • Boston, MA 02114-2017 a www.rnass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractor/Electricians/Plambers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual):'M tees icy Address: cc/ Louie-, • 6cuv pi City/State/Zip: y, Phone#: io f?dU 2 Tor Are you an employer?deck the appropriate box: Type of project(required): 1.0[am a employer with ( employees(full and/or part-time).* 7. ❑New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. (a'Remodeling • any capacity.(No workers'comp.insurance required.] 3. I am a homeowner doingall work myself t 9. ❑Demolition ❑ ys [No workers'comp.insurance required.] 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 1 ❑ Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.0 I am a general contactor and I have hired the sub-contactors listed on the attached sheet. These sub-contractors have employees and have workers'comp.insurance) 13.E Roof repair 6.❑We are a corporation and its officers have exercised their richt of exemption per MGL c. 14.❑Other 152,§1(1),and we have no employees.[No workers'comp.insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. I.Homeowners who submit this affidavit indicating they are doing all work and then hire outside contactors 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 employes 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: C.✓'/t- Policy#orSelf-ins.Lic.#: 4cr400022cm, 3 72/5, Expiration Date: 3/S// Job Site Address: (S S co* cr., 4-i City/State/Zip: YGr.aceh. Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ca t), under the pains and penalties of perjury that the information provided above is true and correct Sigrlattre: / / c/f/ �- Date: Phone#: cock 9, 0 2702_ 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. EIectrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: ACCMCP s CERTIFICATE OF LIABILITY INSURANCE DATE (NIUD• 6�B THS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION OILY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER TIE COVERAGE AFFORDED BY THE POLICIES BELOW. THS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUrHORRED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT If the certificate holder is an ADDITIONAL INSURED,the poIicy(ies).must be endorsed. H SUBROGATION IS.WAIVED,subject to the tensa and conditions of the policy,certain polities may require an endorsement A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsemenl(s). .- . PROOJCER COHTItCT-,.; Schlegel & Schlegel Ins BrokeLL r . +" ;�� ; "wink JUL/8)M771-8381FAX (508) 771-0663 LAC Nek 34 Main Street .;, - . •'iy',, . •schlegelinsuranceegmail.com West Yarmouth, MA 02673 ,. . �,T. INSUREWS)AFFORDING.COVERAGE RACI •,. INSURER A:MOUNT VERNON INSURE! unmet IMBt a:CNA ' , TIMOTHY KEATING DBA KEATING INSURER C: CONSTRUCTION INSURER D 54 LOWER BROOK RD INSURER E: SOUTH YARMOUTH, MA 02664 INSIIRHIF: . COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICES OF INSURANCE USTED BELOW HAVE BEEN ISSUEDTO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDCATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY TIE POLICIES DESCRIBED HEREIN IS SUBJECT TO AU.THE TERMS, EXCLUSIONS AND CONCITIONS OF SUCH POUCIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE NSR WVD POUCY NUMBER MMIDDNYTY) IWATOMMY) LRa1S A GENEIALUABIITry GL 2548741,-•.;��°-^,•P 3/20/18 3/20/19 EACH OCCURRENCE E 1.000.000 X COMMERCIAL GENE RAL LVBI)TY • DAMAGE TO occurrence) S 500.000 CLAIMSMADE X OCCUR • MED DP(Ary one Rerun) $ 10.000 PERSONAL S ADV INJURY $ 1.000.000 GENERAL AGGREGATE S 2.000.000 COWL AGGREGATE LIMIT APPLES PER PRODUCTS-CONP/OP AGG $ 2.000.000 —1 POLICY n,Eo- n LOCC0 l 0 _ AUTOMOBILE LWBWN (ESINGLE LIMIT S PNYAUID (BODILY INJURY(Pet person) S ALL GIMPED SCHEDULED BADLY INJURY(Per arcident) $ AUTOS AUTOS NON.OHIRED AUTOS AUTOS Dat aeloasM) AGE S aeMM $ HBI,BfELLA LIMB OCCUR EACH OCCURRENCE $ — EXCESS LIAB CLAIMS-MACE • AGGREGATE $ DED RETENTION$ $ B WORKERSCOMPENSATION 6S59UB0224N37214 3/9/18 3/9/19 IT RYIMRAI IGCRH- M1D EMPLOYERS'LIABILITY MY YJN ANNIA E.L.EACHACOCENT $ 100,000 Of-KERNEMBER EXCLUDED? (Mande lory In NH) E.L.DIS EASE-EA EMPLOYEES 100,000 ryes,desad»rakler DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIAR $ 500.000 CESCRIPTION OF OPERATIONS r LOCATK)NS I VEHICLES (Math ACORD 101,Aellronal Rowena Schedule,*more mace le rend red) TIMOTHY KEATING HAS ELECTED TO BE COVERED UNDER HIS CURRENT WORKERS COMPENSATION POLICY • CERTIFICATE HOLDER CANCELLATION • SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DEUVERED N ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZES REPRESENT/ME • I . ®1988-2 i COR• ORPORATION. All rights reserved. ACORD 25(2010/05) The AC ORD name and logo are registered marks of A • -D Phone: Fax: E-Mall: Keating Construction dgis PROPOSAL Home improvement contractor registration: DATE August 28,2018 143053 Quotation it 1 54 Lower Brook Rd So.Yarmouth MA 02664 Phone(508)760 2702 • timkeating66@hotmait Quotation valid until: October 28,2018 Proposal for. Job name/location: Suzanne Teuteberg Same 155 South Sea Ave V FSeeth-Yarmouth Ma �J Qpr 508 77 1 1301 . "'� � fJ (. 7 We hearty submit specificatons and t ,-D striPticr.v�'l�x. v .� w A .. . .'W. S n r, Y ,. ,..� r . N a .. Strip roof shingles off entire house and shed roof Install 3 ft of ice shield on all lower edges and valleys • Install 30 lb tar paper Install new vent pipe flanges Install new white 8 Inch drip edge Install Certalnteed Landmark 30 yr architectural shingles • Install ridge vent on all peaks • Install new lead chimney flashing on 2 chimneys • All debris and trash vnll be removed and disposed of property Only items specified above are 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 s of 59,500.00 ' Senior Citizens discount included 113 payment due at start of j•b .-• • .inder upon completion Acceptance ofProposad_N Date of acceptance: K/29- Acceptance of Proposal: r ��`_ Date of acceptance: C1(n/ The above prices,specifications and conditions are satisfactory and are hereby accepted. Gk • tai , • Commonwealth of Massachusetts !,�f Division of Professional Licensure Board of Building Regulations and Standards Con structiO1 S M$9rSpecialty /j CSSL-099351 Wires: ;'3 ' i / a , i' i; TIM B KEATING - -. :Jr54 LOWER BROOIQ_RO D `" � r 'ir,. • SOUTH YARM6F1/TH M 2664 .44+ I '1i. Commissioner ge Vontma/notch%W''/6uader Office of Consumer Affaits&Business Regulation ' HOME IMPROVEMENT CONTRACTOR TYPE:Individual Registration flpira9o11 143053 . 06/13/2020 TIMOTHY KEATING - DB/A KEATING CONS_LTI 54 OTHY WER ROOK R . 54 LOWER BROOK RD. ' atcciatt— SO.YARMOUTH,MA 02664 Undersecretary