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Home My WebLink Aboutbld-20-004563 i I E C E V E --F—/331 : _I ( I I Ilse 4f�b�n, E � ermd4a0 S� fkr _,_; L. t3 ..,l " `�3 BUILDING DI-r�AR 'i Amount 1 n c-e. q �� — 1 Permit expires 180 days from as�� - --� issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 (508)398-223 1 Ext. 1261 CONSTRUCTION ADDRESS: 26 Pic 1,, `/t./- 1 , c/J (/l.,` ASSESSOR'S INFORMATION: I I Map: Parcel: OWNER: htJlinGrn �eA14,-iC ?O 010C 1-0 Y4,-pied-2-. NAME PRESENT ADDRESS (� TEL # CONTRACTOR: f‘i !C e4*i 1f S(IG U W'`C' 6f 44,1 gc° V1iJihNAME MAILING ADDRESS TEL.# ��LL low 760 27aZ, t A esidential 0 Commercial Est.Cost of Construction$ 5SOO r� Home Improvement Contractor Lic.# /tr16153 Construction Supervisor Lic.# 943 S'1 Workman's Compensation Insurance: (check one) / • C I am the homeowner I am the sole proprietorpJ *+4 have Worker's Compensation Insurance Insurance Company Name: C ✓v (4 Worker's Comp.Policy 6 5 5' () 61 72 (,t' `1 3 72/ +' WORK TO BE PERFO??MED Tent Duration (Fire Retard Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Rooting: #of Squares 13 ( ).$imove existing'`(max.2 layers) insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Ponl fencing the debris will be disposed of at: Y•p/Aide ettA- Location ofity 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 revocation of m nse and for prosecution under M.G.L.Ch.268,Section I. 1 I / Applicant's Sianattve: _ `�� Date: 2/! [ 20 ZU Owners Signature(or attachment) e Date: /// eeee Approved By: e r Date: i ^/2-----2cr Building ci r d ignce) E .ADDRESS: Zoning District:_ Historical District: Yes No Flood Plain Zone: Yes No Water Resource Protection District: Within 100 ft.of Wetlands: Yes No Yes No • The Commonwealth of Massachusetts Department of Industrial Accidents .=all- 1 Congress Street, Suite 100 `} t_` 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): "rem Address: .S`( i-Du.e r &co z j21 City/State/Zip: /cY-rl&Jh- Phone#:Sic 760 2-)riz Are you an employer?Check the appropriate box: Type of project(required): I am a employer with / employees(full and/or part-time).* 7. 0 New construction 2.0 am a sole proprietor or partnership and have no employees working for me in 8.t Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]1 10 Building addition 4.0 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 11.0 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.t 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.0 Other 152,§I(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: t-474 Policy#or Self-ins.Lic.#: (S"S4 v 6c 22 ,'/1 372/ r Expiration Date: 31r/2e.> Z J Job Site Address: Zd Q e Lv, City/State/Zip:yl/muJ/ 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 certify under e pains and penalties of perjury that the information provided above is true and correct. Signature: Date: 21 /S / 2d 26) Phone#: S 0 ? 7 0 Z 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 b.Other Contact Person: Phone#: Keating Construction � ) Home improvement contractor registration: DATE February 9, 2020 143053 Quotation# 1 54 Lower Brook Rd So.Yarmouth MA Phone(508)760 2702 Proposal for. Job name!location: Kwinam Leblanc Same 20 Dove Ln Yarmouth Ma 0i26 508 367 8159 cJ We heaNi sbBiinit s catons and Description Strip roof shingles off entire house Install Certainteed ice+water shield on all lower edges and chimneys Install Certainteed Roof Runner 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 Rework lead on chimney as needed f) (.41'0d(I All debris and trash will be removed and disposed of properly Only Chimney flashing specified above e are included in this proposal. 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$5,500.00 Balance due upon completion Acceptance of Proposal: Date of acceptance: a/ /6 (1 ?J:i v Acceptance of Proposal: Date of acceptance: Z//Z../ The above prices, specifications and conditions are satisfactory and are hereby accepted. 1✓re Torir nwea/!/a oft�3 l(a.kta+lucte/T,i • t (' Office of Consumer AffaIFSA Business Regulation ®! Division of Professional Licensure • HOME IMPROVEMENT CONTRACTOR Board of Building Regulations and Standards TYPE:Individual Constructioo-,544hAspr Specialty Registration Expiration 143053 06/13/2020 - '"'.• CSSL-099351 = ECAires. 05/11/2020 • TIMOTHY KEATING ; , _ D/B/A KEATING CONST t; TIM B KEATING + 54 LOWER BROOK •*' TIMOTHY B.KEATING SOUTH YARMO TH MA' 54 LOWER BROOK RD.. SO.YARMOUTH,MA 02664 Jti� 1:,L) Undersecretary , Commissioner A CERTIFICATE OF LIABILITY INSURANCE DATES INDENT'") 3/19/19 THS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERrIRCATE HOLDER Ills CERTIFICATE DOES NOT AFFRIAATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POUCES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING NSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: I Me certificate holder Is an AbOr1ION/it.INSURED,the pollcy$es)must be endorsed. If SUBROGATION IS WNVED,subject to the terms and conditions of the policy,contain policies nuy esquire an endorsement. A statement on the certificate does not confer ruts to be certificate holder in lieu of such sndaresment a). sPRODUCER1 6 Schlegel ta I= J_ULI MCDOOWELL Schlegel egel Ins Broker lei ricestay (508) 771-8381 (SOB) 771-0663 34 Main Street : schleaelinsurance4gaail.co. Wast Yarmouth, MA 02673 INWIREWIRAFFORDIND COWDLN E--- I, NAIL A IM URpt A:NAUTILUS____ M°URED lounge s:CNA i TIMOTHY I03AATING DBA ICEATING CONSTRUCTION INeu c; { IKM54 LOWER BROOK RD Ii)•.___.---____-- —ll ' SOUTH YARMOUTH, MA 02664 ._____ _ .- MUM F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICES OF INSURANCE USTED SOW HAVE BEEN ISSUED TO THE INSIRED NAMED ABOVE FOR THE POLICY PERIOD INDICATE) NOTWITHSTANDING ANY REQUIREMENT,TERM OR COMITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESORNBED HEREN IS SUBJECT TO AU.THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POUCIES.LMTS SHOWN MAY HAVE BEEN REDUCED BY PAD CLAIMS. TN` TYPE OF INSURANCE y pOL1Pl NUMBER °MM�IY ;JAN YYY)f UNITE A GENERALUAaLITY GL 2548741 3/19/19„ 3/19/201 EAcmOCCURRENCE s L1,QQQA0Q..� X- CC RIERClAL GE NER AIL IMIUTY DAMM(�iETO RENT D FREESES EaAmrmaU s._.__500,09A CLAP.O MADE I }(, OCCUR RFD Elm(Any ores parson) .-s. IQ,400 r PERSOINLILAOVINJURY I$ .1.,000,00,0 _._ j ,GENERAL AGGREGATE 1 s 2,000,000 GENLAGGREGATELMT APPLES PER L PRODUCTS OGPPAPAGO f tt s?�000,000 r' I POLICY I PRO- i ECT I LOC s AUTOMOSN,!WOLI V COSIOSED SINGLE NIT ANY AUTO BODILY INJURY(Par noon) ,$ ALLOYYAE0 SCHEDULED __....-__ ... _._.... AUTOS AUTOS BODE Y INJURY(Pot axidens f NON.ONNED PROPERTY 0,MGE 1__HIRED AUTOS AUTOS s a aacrdrtj ,s UNSfieLLALWI OCCUR EACH OCCURRENCE,' $ I _ EXCESS Wla CLAWS-AWE AGGREGATE s OW RETENTION$ s B WORKERS COMPENSATION 1 6859UB0224N37214 3/9/19 3/9/20 g wcSTATU I Iarm- AND rlIPLOYems LNe1LITY Y/N YRSi • F a _ PINY PROPRIETORtPARTNEREXECUTNE 'EL EACHP4CHIE,N1 S. 0 0 -._..__1000_._. OFFKERNENBE R ML Lr>E09 1 N 1 A! pla nMbry en NH) i ,EL ORME-EA H,APSOrEEI s .----100.._000_ Wyyeas daaibaundar ff . OESCRIPTIDN OF OPERATIONS oww i EL.DISEASE•POUCY LIAIT i$ 500,000 I DESCRIPTION Dr OPERATIONS I LOCATIONS/VEMMILE!(AWE ACORD NI,AdAms,U Ibuerts INENNEN,N more*OOP la Argo AAA TIMOTHY KEATING HAS ELECTED TO BE COVERED UNDER HIS CURRENT WORKERS COMPENSATION POLICY • CERTIFICATE HOLDER CANCELLATION • SHOULD ANY OF 1ME ABOVE OE salaam POLICES SE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL RE DEUVERED N ACCORDANCE WITH THE POLICY PROVISIONS. Irt,g// . 01911$ . 10 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered mane of ACORD Phone: Fax: E-Mail: