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Office Use Only
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EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department i lL , ; :,
1146 Route 28
South Yarmouth, MA 02664 `•
/`� 1.(,-111-7. 510(508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS: 7, {-�''rO w 10/YCL,f e Pc,:‘•vii, VO.-11/ t.)Viln y'Ji
ASSESSOR'S INFORMATION:
Map: Parcel:
OWNER: /(Gt l O'4 ri'e'i 7Y F 1'�C�i�.�hf`j ell? / '7iz )476 )
NAME PRESENT ADDRESS TEL. #
CONTRACTOR`"// 0--? ke4 fi/2) S'/ Lu r gr z/ y �
NAME
ADDRESS L.#
� Od
4 Residential CI Commercial Est.Cost of Construction$ /I'"f��
Home Improvement Contractor Lic.# it/3 3 Construction Supervisor Lie.# 99315 J
Workman's Compensation Insurance: (check one) /
[1 I am the homeowner E I am the sole proprietor 1 have Worker's Compensation Insurance
Insurance Company Name: L., 4//'9 Worker's Comp.Policy ‘S c'Jj Q??yii.J 21y
WORK TO BE PERFORMED
Tent Duration (Fire Retardant Certificate attached?) Wood Stove
Siding: #of Squares Replacement windows:# Replacement doors: #
Roofing: #of Squares SUeRemove existing*(max.2 layers) Insulation
Old Kings Highway/Historic"Dist. ( )Replacing like for like Pool fencing
*The debris will be disposed of at: \/6( 7Uv1- l 'i
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 of my license and for prosecution under M.G.L.Ch.268,Section 1.
Applicant's Sign • Date: 2 40//
Owners Si ature(or attachment) Date:
Approved By: v `"t F Date: /Z/.7///
ding Official(or designee) EMAIL ADDRESS:
Zoning District:
Historical District: Yes -1 No Flood Plain Zone: Yes L No
Water Resource Protection District: Within 100 ft.of Wetlands:
I Yes 1 No Yes 7_ No
The Commonwealth of Massachusetts
pt"M��, 1—l/ Department of Industrial Accidents
=:it rii y 1 Congress Street,Suite 100
• _`s'1•'_f'— Boston, MA 02114-2017
*,.r,.1 www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
ADalicant Information Please Print Legibly
Name (Business/Organization/Individual): ! ` h-Zv.11-7)--75
Address: S Lj L(111,e 'Teo lu Pd
City/State/Zip: Y(//}/ram /144 Phone#: ,.-S'W 760 226-
Are you an employer?Check the appropriate box: Type of project(required):
1III I am a employer with f employees(full and/or part-time).*
7. 0 New construction
2.0 I am a sole proprietor or partnership and have no employees working for me in 8. [Zemodeling
any capacity.[No workers'comp.insurance required.]
9. D Demolition
3.❑is am a homeowner doing all work myself[No workers'comp.insurance required.]t
10 0 Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. 1 will
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.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.Q 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 exemption14.Q Other
gh mpti 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.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors 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 j9
Policy#or Self-ins.Lie.#: tg.k `7v L3 0 2?4,iv•_7 Z/9 Expiration Date: 3/ /ZO
Job Site Address: 7 3 1 ro-)l0rv.dJt Ph-t)^ City/State/Zip: vivo),�Zkid
Attach a copy of the workers' compensation policy declaration page(showing the policy num?vivo)
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.
Sitalature: t'-g `-' --p• Date:
Phone#: c) ` 76.6 2 O7,
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 lnsterto5 S,p10/2 1 .
b.Other - r--
C49gIstilibPers.i
Phh ne#-
Pgtone lt:
Contact Person:_
1
CERTIFICATE OF L#AB1Lra rrir INSURANCE DATELinlokANYYI
MS CERTIFICATE IS ISSUED AS A PATTER OF INFORMATION CERTIFICATE DOES NOT AFFIRMATIVELY # ran Y eyn� !I 3/19/1
CERTIFICATE
BELOW. THIS S NOT
IR INSURANCE R NEGATNEE.Y AMA, EXTEND OR ALTER THE COVERAGE AFFORDED��� ""P' '�`S ENTAI uti F4 AVID' DOES NOT A CONTRACT BETWEEN ME ISSUING At/MIMEDTHE
RERiESCERY'il�AATE CERTIFICATE HHOLDER.•
uwi iarrrpt+a�w he cc s cate tickler Is an
P�1Is�r� RED, lie Aot�yGes) must be and
sate fielder in belt/Ousel a policies may requite an Dread. U AM N!3 W ,
oor.naCew endorsement( A lib fitment on this certificate does not confer subject8
I MCDOWELL _Schle I .S. Schlegel Ins 3oker1 Mrrmp4-
PION
I lli, • • 08 77 -8381 •
(soe) 771-0663 Schl linearbIG@�� .l.GOffiWaet Yasapu, , } 02673
I Ineuse SL.APFoma COVERAGE
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INSURER A:NAUTILUS _ _
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CONSTRUCTION INSURER C
54 LOWER BROUtt kb I R—ER—D:
MO RO!E:
SOUTH YARUTH
COVERAGES __ I
CERTIFICATE NUMae'R:THIS IS TO CERTIFY THAT THE POLICES OF INSURANCE LISTED BELOWRENSION NUMBER:
THIS
I i TO, •R- —. HAVE BEEN
IEXCLUSIONS
n�1 Wr I NS i AIVLJIIV(S wvY I'�(�iAFd=MkM I, ISSUED TO THE NSLRED NAMED ABOVE FOR THE
CERT7FICRTE MAY ilE 183t1®OR NG4Y PERTAIN!, THE 1 CONDITION OF ANY ONTRACT bR OTHER OOCUMEM WRH RESPECT T POLICY IS
f_Xq USIONS AND CONDITIONS OF SUCH NICE AFFORDED BY TICE POLICIES DESCRIBED HEREI�1 IS
N •_ POLICIES_UNITS Si IOC MAX HAVE E t RED1 ICED BY pa In meets ACT TO ALL THE TERMS.
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C•1 CAA ?Inc L Caw,L I !DAMAGE TO RENTED , +--1�V//U��v_�_t _
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P 0DPERSONAL 8 ADV INJURY --
I ---- - 3 1.00 0 000 GEAfLAGGREGATEpMTAPp
GENERAL AGGREGATE 1 S 2 000 000
KhH;Y • ItESPER
' LU(; 4UCTS-006PIOPAGG L.i 2 000 000 •_..
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AlIOWiED SCHEDULED
a- d e - —
$
AUTOS AUTOS 1 ; {BODILY INJURY(Per peen) l$
HIRED AUTOS AUTO
j BODILY INJURY(Pertlel $ -
-
UMBRELLA LIAB rE` }---- _
CLAIMS-MADE - -
F.....OCCUR i I $
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1 IAGGl OCCURRENCE
DED RETE!(T i - f I AGGREGATE s '-
$ KIM COMPENSATION - _
� � YIN 6859UB0224N37214 3/9/19 3/9/20 X i W p —___
ANYPROPRIE7pRIP QTH
OFFICE nda$S in NNR E><CLUDEM NIA f - - --.`r.. ..
{ i El.EACH AC�t� _ 1 DO 0O0
N�yes tlespriDeuntler !!! I
DEStrRIPT10N 01=OPERATIONS below
%e� n�.casc et
( I E.L.DISEASE-POLICY U MIT $ 500 000
i I
!DESCR,TIp OF OPERATIONS I LOCATIONS/VEHICLES
(A ACORD 101,Additional Reeaks Schack/le,N more saaisw qtardlS 1Tty _R ac In. mnrallown.
TINDER •iY VVmVy..rL.4T •�...�yvd L. Vll.lf+wa.awM +RA.r.�
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CER 7 it ILA!E rr OLuE t
I CANCELLATION
I '-srwuLV Amy use saw ut»:KIBEO POLICIES 8E CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DEUVERED N
ACCORDANCE WITH THE POLCY PROVISIONS. I
AUTHORIZED RE
I
ACORD YS(2010/OS) t 1188-2 10 ACORD CORPORA I
Phone: The/CORD name and IoQo are regist�erad Ail rightser�ed.
Fax: E-Mail:
marks of ACORD
Keating Construction IFir
Home improvement contractor registration: DATE November 3,2019
143053
Quotation# 1
54 Lower Brook Rd
So.Yarmouth MA
Phone(508)760 2702
t mkeating66@,hotmnil corn
Proposal for: Job name/location:
Kathy Obrien Same
73 Trowbridge Path
Yarmouth Ma 02664
781 733 2537
We hearby submit specificatons and
w4 r etA a y $
s� :k : " „ i e"'Yr�',,,,a,..... f f ,.., �a't itG k rsw ? h 'ew'� t cai. �`.? Ar;. i ": r _ k V-44 3 f
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
Install white F 8 inch drip edge
Install Certainteed Landmark 30 yr architectural shingles
Install ridge vent on entire peaks
All debris and trash will be removed and disposed of properly
� a L`z.• :Hy�°a it k"zi.q e tit " � s fiy.G'a ; r' 5 r�/ dW.: �'•�Ns.N� ,�' r a'"`,:1�. �,{i?itf- r' L;A e:.",l .,�y�y#��.�a rt v� '°ie, �i�r#"' t:m' "�" <
... w•»xry, r -� ! rtr * '`y .�. C' rz ..`c` ,� ail s��` x "Cr '�3 "�
kwv�. •+'ems. ` ..�i>� .1; n e.<,., ;� a. „..�•..-.��ea�� vs.,:... sva�Ja-i:;r ,• "0,..d, '�`; .3.:.u;. S£�...•.'`.�a�' q...�?.' a. 4 d �,..W.t. . ..,`t., ' ,
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$7,500.00
Balance due upon completion
Acceptance of Proposal: Date of acceptance: 11( /r I /
Acceptance of Proposal Date of acceptance: /?. )
The above prices, specifications and conditions are satisfactory and are hereby arrpted.