Bld-20-001076 Office Use Only
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Permit expires ISO days from
issue date
— 20--I D-7/
EXPRESS BUILDING PERMIT APPLICATION _ -
TOWN OF YARMOUTH 3 R E C E L V �JL 1
Yarmouth Building Department _„__ . r
1146 Route 28 AUG 201 J
South Yarmouth,MA 02664
11,1
(508) 398-2231 Ext. 1261 gym. P '
CONSTRUCTION ADDRESS: le Or ehi / /-► Vrvic
ASSESSOR'S INFORMATION:
Map: Parcel:
OWNER: 11 uii'L► Orch, /4f�''�G�,r
NAME PRESENT ADDRESS TEL. #
CONTRACTOR: t /4"1 41 15 ..Sc./ Lr1)'r &' ux- /4/4-,�2
NAME MAILING ADDRESS TEL.H L r )Q
,esidential D Commercial Est.Cost of Construction$ 7-S eel
Home Improvement Contractor Lic.# / c/3 ds 3 Construction Supervisor Lic.#
Workman's Compensation Insurance: (check one)
I am the homeowner Li I am the sole proprietor VI have Worker's Compensation Insurance
Insurance Company Name: /v / 1 Worker's Comp.Policy# 06-$$cj t> 6 () e 2(--1 A-)?7 E'Jy
WORK TO BE PERFORMED
Tent Duration (Fire Retardant Certificate attached?) Wood Stove
Sidi #of Squares /U Replacement windows:# Replacement doors: #
Roofing: #of Squares ( )Remove existing*(max.2 layers) Insulation
Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing
*The debris will be disposed of at: Y4r-rY7�7 14-1
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 revocatio my license and for prosecution under M.G.L.Ch.268,Section 1. /
Applicant's Signature: Date: G��i/?7 ( /5
Owners Signature(or attachment) Date:
Approved By: Date:
% -1�
Building Official(or designee) EMAIL ADDRESS:
Zoning District:
Historical District: Yes ! No Flood Plain Zone: E Yes Li No
Water Resource Protection District: Within 100 ft.of Wetlands:
L Yes Li No n Yes 7 No
The Commonwealth of Massachusetts
Department of Industrial Accidents
__=mi_ 1 Congress Street, Suite 100
1 aw
.` t Boston, MA 02114-2017
� Y
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): Ir/h
Address: Sy L Ou>e &'( ' P'
City/State/Zip: Ve-/ ON, Phone#: ?7‘)?
Are you an employer?Check the appropriate box: Type of project(required):
1.11 I am a employer with t employees(full and/or part-time).* 7. 0 New construction
2.❑I am a sole proprietor or partnership and have no employees working for me in 8. E21 Remodeling
any capacity.[No workers'comp.insurance required.]
3.01 am a homeowner doingall work myself. r 9. Demolition❑
❑ y [No workers'comp.insurance requited.]
4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions
proprietors with no employees.
12.0 Plumbing repairs or additions
5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.[]Roof repairs
These sub-contractors have employees and have workers'comp.insurances
6.0 We are a corporation and its officers have exercised their ri gh exemption t of per M(sL c 14.0 Other
.
152,§1(4),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.
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: C t
4
Policy#or Self-ins.Lic.#: Expiration Date / S /Z O
G s 9 (O d 22 '-c,u37 2/
Job Site Address: ) Orck,'Z 1, City/State/Zip: Y4(ev? 1 t/'
Attach a copy of the workers' compensation policy declaration page(showing the policy n mber 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 certify un the pains d penalties o erjury that the information provided above is true and correct
Signature: Date: cS1 Z 7 L
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(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
ATE OF LIABILITY INSURANCE GITE ,
LMS CERTIFICATE l3 ISSUED AS A PATTER OF IIIIF��y A�
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY !�" OUR/MATE 3/19 I
THE POLICIES
BELOW. THIS CES NO A F IR FRANC£ DOES NOT C NSTITUTE MBA EXTEND OR ALTER THE COVERAGE 3 THIS
itEPHIEsIENTA"iiirt OR PR(7i ,M 1 C 14CATE HOLDER A CONTRACT BETWEEN THE ISSUING is AUTHORIZED
ANT: the ce cste older is an
.:won*ani:i ina'iFluae oil p oky,der WWII Poiiaes I D, 91e PoHcyiles)must be olsed. U •i W
,subject certificate holder in lieu of such• 'lequlls an A mate on this certi8cab does not confer to
re
Sehiegel & Schlegel Ins Broker RAW:- (598 MC2�dN&LL
1 3d NA tt at vises, P • _
�Tei9t Y -- - --th 7 -83 - Me) 771-0663
MA 02673 • BOW. $AFPOR Once '1.con
MUM S WORM COVERAGE
eBLMta?D . INSURER*: -_L_ NAilcs
iri IRJJC ?W ien DnA Sii3L*rig I am e:CNA
CONSTRUCTION IIlURBlA: --- — _- _i___-------_._.-
a4 Luw.....Ri� BituOit RD .1..W URA9I o: -
SOUTH YARMOUTH, MA 02664 ►tauRst a _.__
COVERAGESOER IlaURER F: - —
TFpE IS TO CERTIFY THAT THE $OF TIFICATE NUMBER:
1r1iIS IS . ERTI Y T ; Y I CE USTED BELOW HAVE BEEN ISSUED TO THE NUMBER:
CERTYICATE MAY! ISSUED OR MAY4p11 TERM Oil CONOImN OF ANY CONTRACT OR OTHER NAM®ABOVE FOR CT POLICY PERIOD
EERTFICATE MA tlIE ISSUED
OFR MAINTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRI WEB R� CT U WH( i THIS
IN -_,---__ REINS-LINTS SHO NISAYHAVEBE.EAt_ p.BYPA n[lAvg ACT TO ALL THE TERMS.
f ! _ TYPE OF PUKE __-.A � GA3IERALLIAaMLAI'y POU NUMBER ��' ------ ----_._.�.-__-_
!�! 11C£, 254'W7y.1 ! zttati uzg1gQ WITS ,��±
OM�IERCIALGENENULIABRJTY ``^� $ .uuu_OGt f CLAIMS r_n _UR-
owes► ---t--
LfiELr3W y�nroropenmt t s 1_ G
( j---J PBtSQN4LSADVINJURY 1 tt s 1 000 OOQ
GENLAGGREGATELS TAPPUESPER GENERAL
WWII i i (AM�ft F--1 &2.0oOT Q00
ru�nr LOU ' ! i PRODUCTS-COiwcPADD a 000 00
AUTOMOBILE LAMMUTY I _
ANY AUTO f ° I �Ea nll
ALLOWHEO I J I 3
AUTOS AEb BODILY INJURY(Par poison) _ -
HIRED AUTOS ' ' ? 1 BODILY INJURY(Per accident) $ - —
— 1 J�IKJNtftIYUAARA _ _
UMBIELLALUIS F-OCCUR AUTOS
tI� t t
IEE$SM !
t� i EACH OCCURRENCE :
AGGREGATE s
B WORKERS COMPENSATION
6859UB0224N37214 3/9/19 3/9/20 X ST OP_
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E IDED? rj i N I A
Msedsbry in NN) �3 E.L.EACH OE 1 QQ QQQ
tlY deeoribeurgar r
OMiefI TIOR OF OPERATIONS below 'c L. G ct,, w
EL.DISEASE-POLICY LIMIT 00 000
1 I
DESCRIPTION of OPERATIONS I LOCATIONS VENOM1 I
(Meth AOOIM 101,Adwart+l Wends ININOI s,snare spew Is',plod)
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TT14 �CJASTT1i,�, x�.ag Ler„Er•n�e, er, e n2
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IC717
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CEi i-WFICA r E HOLDEN
CANCELLATION
I. a'iw-ilLj Adis'.OF 1HE*NO*OtzwfusEO POUGES Nf-i CANCELLED BEFORE TIME EXPIRATION DATE THEREOF, NOTICE WILL BE DEUVERED INi ACCORDANCE W TH1 THE POLICY PROVISIONS.
I AUAIONEED RE :
1
__.1.. °F l
019S$.1oACORD CORPORATION. All rights roomed.ACORD 25(201(WOO) The ACORD name and logo a
Phone: Fax: Ems: re>glisbend maMics of ACORD
Keating Construction
Home improvement contractor registration: DATE July 26, 2019
143053
Quotation# 1
54 Lower Brook Rd
So. Yarmouth MA 02664
Phone (508)760 2702
timkeating66(a.hotmail.com Quotation valid until: September 12, 2019
Proposal for: Job name/ location:
Kathrine Stebbins Same
18 Orchid Ln
West Yarmouth Ma
617 645 8704
We hearb submit s•eciflcatons and
Strip sidewall shingles of front main house, back main house walls and leftside gable wall
Install Typar house wrap
Install new window cap
Install Clear Cedar sidewall
All debris and trash will be removed and disposed of properly
Only items specified above are included in this proposal.
Rotted wood repair is not included in this proposal. $35.00 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: $7,500.00
1/3 payment due at start of job and remainder upon completion
Acceptance of Proposal: ,i ate of acceptance: .1414 ' f"5,
Acceptance of Proposal: Date of acceptance: �)27/f 5yryU
The above prices, specifications and conditions are satisfactory and are hereby accepted. „//, �� >
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HOME!Office of nsumerMaininaizeoetzlia $Bu �
MPRyVEMENT CONTRACTOR
Regulation
L3egIndividual�RACTOR
str
TIMOTHY 143053 it ti n
D/B/A T ING O6/13/2020 -
KEATING CONST_
TIMOTHY B.KEATING
54 LOWER BROOK RD.
SO.YARMOUTH,MA 02664
Undersecretary
Licensure
` r Di Commonwealth owealth of Mass
Board of Bui! f Professional Massachusetts
ding and Standards
CSSL-099351 evsr Specialty
,�►res
05/11/2020,, fit 1 k•TIM g KEATI y54 gSpUTN YgR 26
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