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Home My WebLink Aboutbld-20-002434 *Y .Office Use Only 4 4i Permit# , C ' n/ Y S 0 y. Amount , kftwv E Peru it expires 180 days from '1 issue date �'-Iac 20-243I EXPRESS BUILDING PERMIT APPLICATIOPE C E t V t i I TOWN OF YARMOUTH ____...._ Yarmouth Building Department OCT 2 9 2019 I I 1146 Route 28 South Yarmouth, MA 02664 B U I;E_...y.. __Pprreir ,� (508) 398-2231 Ext. 1261 .. Y-. 1_-1 CONSTRUCTION ADDRESS: C ei G,!' CroA4Cv J'c Y4747 a &&- ASSESSOR'S INFORMATION: / Map: Parcel: ,)) �/ p 127 OWNER: �� (l� �� 5L/'� b 4,p-f-'Gtr/` (r0e-/t'er D�`t. ye,/picult- NAME PRESENT ADDRESS TEL. # CONTRACTOR: -`M k 'd.17!i s St( / u e '&c 1 U 11 Yrw!uch 'e*+ NAME MAILING ADDRESS TEL.# CO 76d 27192 lResidential ❑Commercial Est.Cost of Construction$ (, 3SO cJ Home Improvement Contractor Lie.# / Cf 70$3 Construction Supervisor Lic.# QS 3f l Workman's Compensation Insurance: (check one) i1 I am the homeowner El I am the sole proprietor II have Worker's Compensation Insurance Insurance Company Name: 6-/V4 Worker's Comp.Policy# 6 5 S'S tJ AO??L(,IJ 3 7 2/y WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares 22 ( )Ree existing*(max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing • *The debris will be disposed of at: Y4(h'I 4/7)7 '-` /4141 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 of my license and for prosecution under M.G.L.Ch.268,Section 1. )) Applicant's Signature: I Date: Id 2 k1/S Owners Signature attachment) Date: Approved By: l�r X Date /0'� Building es' ee) E jADDRESS: Zoning District: Historical District: 7 Yes 1 No Flood Plain Zone: 1 Yes C. No Water Resource Protection District: Within 100 ft.of Wetlands: LI Yes 1 No 7 Yes _ No The Commonwealth of Massachusetts 5l / Department of Industrial Accidents t :�1.= 1 Congress Street, Suite 100 _`��:- Boston, MA 02114-2017 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): Address: cti glevu R' City/State/Zip: \f7t'1 catit V1v4 0 26'y Phone#: Se)ef- 7cc 27C) Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with I employees(full and/or part-time).* 7. ❑New construction 2.0 am a sole proprietor or partnership and have no employees working for me in 8. ' Remodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑Demolition 10 p Building addition 4.Q I am a homeowner and will be hiring contractors to conduct all work on my property. I will 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.insurance? 6.0 We are a corporation and its officers have exercised their right of exemption per MGL 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: ( /j/4 � Policy#or Self-ins.Lic.#: 6 5.e7 v p d 22 '( Z 3 7 2/if Expiration Date: 3/4 7Zd Job Site Address:g- I4)./ r.!t Cr'OcG ,- City/State/Zip: 1�V, 217O Attach a copy of the workers' compensation policy declaration page(showing the policy ndmber 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$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Siertatu e: ' Date: A0/ 21 Il Phone#: . ,F 7 6o ?7 C'2 Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 1 . CERTIFICATE OF LIABILITY INSURANCE �. �..I Yx, THISIS CERTIFICATECERTIFICATE Eg Np A OF OPO i 0 Y: 3/i9 1 BELOW. THIS OESTIH T AF AFFIRMATIVELY OR NEGATIVELY AMEND, ?ER NO!WISIIII UPON THE CERTIFICATE .�" .. AUTHORIZED . RTAR E C IR j p� YE DOES NOT A 7 CONTRACT BETWEEN B1'LTHE POLICIES ' �oe cafe holder.N BR I M:weft anq lii - .. t� as)1�af�)1e , II he- certificate holder In Wu of suchy poJtCMs nlhrn'�a� A ataterrlsnt on this subject to 9eoo sa cMiflcllta doss not,tatstiar �.# Schlegel & Schlegel �. Ins IIroker rllo ALL I West Yarmouth 771-8 me) 771-0663 r EII4 02673 • ec111 linsuran INSURE AFFORD MUTED �__ _... -_ _ _- -- -- INIURERA:)[�jA,(jTjj+Q$ �- —; 1 u�-HY ""' INeteRBt 6:CNA ------ i aVbAYllVls Ltl!► > :A1 tV(: ', CONSTRUCTION Rey c: ___.._---_ $d j•�'lt Resuui itu I D: — -- —_�_ SOUTH YJTH02664 - - 02664 _ ---- COVERAGES I�BURBt P: _____I___________ THIS IS TO CERTIFY THATPOLICES-OF CERTIFICATE NUMBER: THE POL. S OF to t.ISTED BgOW HAW BEEN ISSUED TO THE REVISION III» rfHS i�iw►Trr�ti�trDivr;AIvY hLEt,XpftEt�,11, >�OR THIS CriCAYE . MAY!N: ISSUED OR MAY PERTAN,THE INSURANCE OF ANY CONTRACT OR OTHER NAM®ABOVE FOR THE POLICY PERIM E7cRTFI AT lAY S NL�fT•1(IAig.OF NSURANCE AFFORDED 4Y TIE POLICIES DESCRIBEDSUB RESPECT U. . 1 . SUO4 PEE UCEs_CANTS SHOIMkt MAY HAVE MEt�t ACT TO ALL THE TERMS. L1�Y Ppgl(]l q TYPE!#`1NWAUY�ItM A. I GENERAL UAIII AT1! POU ! �_.. . 2548?'.1 vigil 3L3412�! UNITS j_COhMtERCULLCiENEA4—L-l�M1BkITY � + f cii-c`�u"torac i �� ' I j7-4 • s _500 -AD-- ( j iMe rF ord L cy wn f_ I PERSONAL P�sa7) I i .,U 4 ? 1 a ADV INJURY $ 1 000 Qoo 1 GERI AGGREGATE LAST APPLIES PER I ! I GENERAL AGGREGATE_ t atnn;r tu: ' i PRODucrs-c_o nnP s OO 2 ak2 AUTOMOBILE UABIUTY i I MY AVID ALLOYiIDED gFD I �aaod rt) S AUTOS AUTOS ' I BODILY INJURY(Per person) - _---, H AUTOS OS I I f 80DILY INJURY(Per aori0erd) $ UfIBIEUAU I OOCUR $ EXCESS UAB t-cLAi smADE i EACH ENO@ $ AK' COMPENSATION AGGREGATE i _ _ i nINV 7EWTNE N►A50'�'�47214 3/9/19 3/9/20 WCSTATU- OTN. !HIV i omcERtaikeERTnOV a-wx+r r.n. «yyad. N ( E:t.ECtiAC«# t �YQ,___0 1;War I N TIONS below, I t OPERA CcL.ru.SE ,. „..,ce 1 _ w El.DISEASE_POLICY LIMIT 00 000 /VEHICLES ! i anaemia /IGOIITgNP I (Add,ACORD ot,A -'�'T► 1'rK�r ir, q�T spa WIIacwRre.rlec8glawila.K mare,y�casM,, ) i\C. Cadpraitat72M1 L1 1 I Z I IF hA■' HOLDER CANCELLATION fiiiCK LU war 00;1NE MBA*Ukst: ttt I THE EXPIRATION DATE THEREOF, EDP Es jE CANCELLED DELIVERED I I ACCORDANCE WITH THE POLICY PROVISIONS. WItl se DEUVEREO N Ao' ED RE • ACORD 25(2Q1 I ®1l11� 10 ACORD t Phone: Fax: The-ACORD name and logo an reerad niyl of ACORQ A� reserved. &Mali: Keating Construction 4e Home improvement contractor registration: DATE October 1, 2019 143053 Quotation# 1 54 Lower Brook Rd So. Yarmouth MA Phone(508)760 2702 timkeating660hotmail.com Proposal for: Job name/location: Phillip Wright Same 8 Captain Crocker Rd Yarmouth ma 02664 413 345 0306 We hearby submit specificatons and Strip roof shingles off entire house Install ice+water shield on all lower edges and chimneys Install 30 lb tar paper on entire roof Install new vent pipe flanges and new 8inch drip edge Install Certainteed Landmark 30 yr architectural shingles Install ridge vent on entire peaks $8,500.00 Remoyssidewall chimney side wail entire reshingle install cricket behind chimney $700 Suppb).` hhingles and roof cap for back shed $150 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. Materials guaranteed by manufacturers. Workmanship guaranteed by Keating Construction for 10 years. We propose hereby to furnish materials and labor for the sum of$9,350.00 Balance due upon completion ( ,f Acceptance of Proposa W P Date of acceptance: `d 1// "9--Cl 7 Acceptance of Proposal: Date of acceptance: d e�(111, 01 The above prices, specifications and condi ions are satisfactory and are hereby accepted. Yy, 7e Pwmanu a t eOffice of Consumer IBusioss RegulationHOME IMPROVEMENT CONTRACTOR CTORTYPE: ndividual II 143053 ' 06/13/2020 .,.,. TIMOTHY KEATING D/B/A KEATING CONST, TIMOTHY B.KEATING 54 LOWER BROOK RD.- �\�.C�'. SO.YARMOUTH,MA 02664 Ll u Undersecretary ,i lVDCommonwealth of Massachusetts - ivision of Professional Licensure Board of Building Regulations and Standards Construct�oo; Ijf CSSL-099351 1itio�Specialty t i Ejt�ires 05/11/2020 MI KEATI z � 1 , ,y ' - 54 LOWER B Olt- stI y SOUTH YARM I4T14 '' r 1"61 i:iO • Commissioner '