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Home My WebLink Aboutbld-20-000662 g•Yq' Office Use Only �: . i.. , C, Permit# 0� Ik,-4104g i . Amount �O • M � ital)" ) D- `r `r Z Permit expires 180 days from issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH RECEIVED Yarmouth Building Department ------� 1 i46 Route 28 AUG 0 5 2019 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 -- - - -- - nn BUILDING DEPARTMENT CONSTRUCTION ADDRESS: %L ()1 ' ti P l fv7 e„ rL,y ASSESSOR'S INFORMATION: Map: 1 Parcel: 1 1 OWNER: t,' C'-'' 5 / `/ CI C Z`/ I j(wt✓(,,1/ L.r Gvr,i 1- (//e.,-/o1,v?'l NAME PRESENT ADDRESS TEL. # CONTRACTOR: 1�1 ( fin)' S `( L p w�.r it;r::'v ,(r- >`-, ,,,,:rit,„.11.1, NAME —__- _, ... MAILING ADDRESS TEL.# Sc•f JG 4 a )c'% 4 Residential 1 Commercial L Est.Cost of Construction$ Sa S 00 Home Improvement Contractor Lic.# / I/ 3L'5 Construction Supervisor Lie.# 5 s.1 / Workman's Compensation Insurance: (check one) U I am the homeowner I am the sole proprietor -Z/I have Worker's Compensation Insurance Insurance Company Name: L /`� 6 S S � -- ---------- Worker's Comp.Policy# Ej,: v1 U 2?Y-✓_3 7?i WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate'attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares Z o ( )Ren4ove existing*(max.2 layers) Insulation Old Kings fiighwayi'Historic Dist. ( )Replacing like for like Pool fencing 'The debris will be disposed of at: `161�"l '✓` Location of Facility I declare under penalties of perjury that the statements herein contained arc 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 m iicense and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: /VC Date: SJ`(/i Owners Signature(or attachment) Date: Approved By: f ;;;?.:;;;i_- Date: g��/, Building Offici ,or d n EMAIT.AD S. Zoning District: Historical District: .— Yes '] No Flood Plain Zone: Yes C No Water Resource Protection District: Within 100 ft.of Wetlands: I ,1 Yes I No 7. Yes No The Commonwealth of Massachusetts ._ 1� / Department of Industrial Accidents s :=+�.— 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia \Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Pi-int Legibly Name (Business/Organization/individual): n 1 /z iz%6 -7 n S' Address: SL! L , City/State/Zip: �-'Gt, iv7;,,,•rZ, h1,4 C 26(.7 Phone#: - 76 c 2 6 i Are you an employer?Check the appropriate box: Type of project(required): 1.11 I am a employer with I employees(full and/or part-time).* 7. 0 New construction 2.01 am a sole proprietor or partnership and have no employees working for me in 8. ['Remodeling any capacity.[No workers'comp.insurance required.] 3. I am a homeowner doingall work myself t 9. u Demolition ❑ y [No workers'comp.insurance required.] 10 ❑ Building addition 4.❑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.D Roof repairs These sub-contractors have employees and have worke=-s'tomp.insuran e.t • 6.❑We are a corporation and its officers have exercised their rightof exemption 14.❑Other pti per MGL c. 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. 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 akto-ootarastois 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: ( ,/)/ A Policy#or Self-ins.Lic.#: C 5 �, 0 ,2 <rr s�) ' ( e j Expiration Date: `3 /y /Z 6) Job Site Address: 2`i City/State/Zip: VC; c t 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 impriscinment,as well as civil.pe" Ities•in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Sisznature: , ��'` Date: ll � S � 1(� Phone il: .c'( ?O G ?v Official use only. Do not write in this area,to be completed by city or town officiaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: • • i4 I CERTIFICATE OF LIABILITY INSURANCE °"'E""'DD"""") 3/19/19 PIS CERTIFICATE IS ISSUED AS A MATTER OF*FORMATION OILY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NOT AFFIRMIA11 ELY OR NEGATIVELY AMEND. EXTEND OR ALTER THE COVERAGE AFFORDED BY TIE POLICES BELOW. TUBS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUIG INSU RER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,MID THE CERTIFICATE HOLDER. IMPORTANT: N the certificate holder IS en ADDITIONAL INSURED,Vie poNcyp.)neat be Endorsed. If SUBROGATION IS WAIVED,subject to the tome and conditions of the policy,certain policies miry require an endorsement. A statement on dde certificate does not confer rids to lie certi$cattholder MI*.of suckendoCINXIMIWIW. mooucan gar, _JULI. MCDOFA.LL Schlegel & Schlegel Ins Broker PHONE 34 Main Street I Sa k (508) 771-8301 T mit (509) 771-0663 West Yarmouth, MA 02673 f.:1 = schlegalinsuranoe5q nail.cos DISWICIIMMIFOROIND comwt r i _ NAIL r INR fi5R A:NAUTILUS INSURED wamm e s:CNA TIMOTHY !EATING DBA lCEATINC - INSUITER C CONSTRUCTION IN1V IRO: 54 LONER BROOK RD SOUTH YARMOUTH, MA 0266d I' 81 __ _.__ _ _tNBURERF: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICES OF INSURANCE USTED BELOW HAVE SEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERHOO 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 AU.THE TERMS. E)OCLUSCNrS AND CONDITIONS OF SUCH POUCIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAt)CLAMS. tit TYPE OF INSURANCE lACOLAUSIR PONWF Penmen MCA LN'S A GENERAL U ILITY f3/19/20 EAcHOCcuIENCE _..s.�...QQQ_...Q.JO_. X cCIM4tERC tiENEwtt IMBLITw GL 25d8741 3/19/19 DAMAGE TORENtED . PREMISES tFaamatCM* $._. 500.00.0 1 CLARRINADE I x OCCUR j AED ExP(Any ono pars) S ]Q.J 000___ PI:RsONAt a K3vNuuaY 1 9 ,000,000 1 L G NEM AGGREGATE s 2,000,()00 GENL AGGREGATE I.MTAPPLESPER i i PRODUCTS CDAPIOPAGG '$ 2,000,000.__ (POLICY' ' I LOC OUTOMOSILS U NNUTY i: ANY AUTO 1 BODILY INJURY(Pie L*50n) .$ ALLONRED SCHEDULED AUTOS AUTO* BOXY INJURY(Par accident).$ NOFJOYMEL_HIRED AUTOS D PROPEiIfY DAhNOE dPa aeedswti _.._ _L._-__..__.... INOREU.AUAW OCCUR EACH OCCURRENCEi ..._ t acme UM; CLAMS-WOE AGGREGATE S ow RETENTION i MWONK�CpMENIATIp/ t & MDmutormerL1AINUTY j ETO 6859UB022dN3721d 3/9/19 3/9/20 g( YsT �I ANY PROPRIRtPARDIERkMOJTNE TeN OFFICERMEANEREXCLWEOo J.NtA El.EACH S._ 109,000_ Mrda�l,d'e aikiNTI)r i ; ' EL.DISEAW-EA ORLOYEF,S ._.._.102,000._... OESCRIP>IONDF oPERATHNaSeleow f EL.DISEASE-POLICY LIAR]$ 500,000 I , oescu n0N OF OP6IATIONS a LOC MELONS a VD*CE5 With ACORD M.Adllipmal Ri(wda&hobla,Y mon woo N toga no TIMOTHY KEATING HAS ELECTED TO BE COVERED UNDER HIS CURRENT WORKERS COMPENSATION POLICY CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE OESCHMIED POLICES BE CANCELLED SEPOIE THE EXPIRATION DATE THEREOF. NOTICE WILL SE DEUVERED N AODORDANCE WITH THE POLCY PROVISIONS. AUTHORIZED RE i 40108$ 10 ACORD CORPORATION. AN rights reserved. ACORD 25(201 WOS) The ACORD name and logo are registered marks of ACORD Phone: Fax: E 4ail: ' A in r�/ze'dmnnonu,eal or/7 Office of Consumer Affai s g Business Regulation HOME IMPROVEMENT CONTRACTOR ii • TYPE:Individual i r i n i ti n 143053 06/13/2020 TIMOTHY KEATING DB/A KEATING CONST. TIMOTHY B.KEATING 54 LOWER BROOK RD. C.SO.YARMOUTH, MA 02664 Unde ®f Commonwealth of Massachusetts. Division of Professional Licensure Board of Building Regulations and Standards Constructiao-Slj r Specialty CSSL-099351 !j „pires: 05/11/2020 TIM B KEATING ..(` 54 LOWER BROOK - ' SOUTH YARMOTN tef ' .'" M .,26 Commissioner C Keating Construction ike ii?i c'a'v si se*rii`s S3 Cirauz[iz regisivatiart DATE August Z 2 .t 143053 Quotation.# 1 54 Lower Brook Rd So.Yarmouth MA 02664 Phone(508)760 2702 timkeatind66@hotmail.corn Proposal for: a Job name/location: .�e'taide.-5�6 L 24 Brook Hill Ln Yarmouth Ma 508 775 4703 We hearby submit specificatons and Strip roof shingles off main house only and renail any loose decking all_Certaintaer1 wgtPr_and _A field on,lower ofIrjec anci_c.iixnnays. Install new vent pipe flanges Install new white 8 inch drip edge Install Certainteed Roof Runner synthetic paper Install Certainteed Landmark 30 yr architectural shingles Install ridge vent on all peaks Install Certainteed hip and ridge wind warranty 130 mph All debris and trash will be removed and disposed of properly Qnly 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. $35.00 per hr+materials if needed Materials guaranteed by manufacturers. Workmanship guaranteed by Keating Construction for 10 years. 1/3 payment due at start of job and remainder upon completion Acceptance of Proposal: Date of acceptance: cf-f 2- I/ S Acceptance of Proposal: Date of acceptance: r The above prices, specifications and conditions are satisfactory and are hereby accepted.