BLD-23-005806 y44 L K) J2:W 1 3 Office Use Only
k*1 Permit#
ojtglil 0 'I,r!. y Amount 5-0.
,'� MATT M s 44.
.• � ne*$r t+a. Permit expires 180 days from
�„; ...•
issue date
BL-b - i3 - ad5e-dO
EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH R E C E 1 V E U
Yarmouth Building Department -
1146 Route 28 � 1 g023
South Yarmouth, MA 02664 AP
(508) 398-2231 Ext. 1261
BUILDING DEP:�RTMEN7
CONSTRUCTION ADDRESS: Sprv�s ei I.? /G(�yr? v (a E -D L
ASSESSOR'S INFORMATION: `
Map: Parcel:
OWNER: 0 ov(. Se I f Zr?A 7� {I,
NAME PRESENT ADD TEL. #
CONTRACTOR: 7T 1 k 47(') SI NAME MAILING L Deer f^ t/G!re i-0,7� �
ADDRESS 6 TEL,# ) 7 zp z
ji Residential ❑Commercial Est.Cost of Construction$ 6?S'
Home Improvement Contractor Lie.# ` 141(?s 3 Construction Supervisor Lie.#d s s f 7
Workman's Compensation Insurance: (check one) �,,r
❑ I am the homeowner CI am the sole proprietor �P t have Worker's Compensation Insurance
Insurance Company Name: C A/4 Worker's Comp.Policy# CS's 5 Al Z`1,22, e 23
WORK TO BE PERFORMED
Tent LI Duration (Fire Retardant Certificate attached?) Wood Stove LI
Siding: #of Squares Replacement windows:# Replacement doors: #
Roofing: #of Squares 13 (5)Remove existing*(max.2 Iayers) Insulation I I
I 1 Old Kings Highway/Historic Dist. Replacing like for like Pool fencing l l
*The debris will be disposed of at: '61 d y1 o)
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 revocati f my license and for prosecution under M.G.L.Ch.268,Section 1.
' Applicant's Signature: Date: V/ I r/ Z�
Owners Signature(or attachment) Date:Approved By: Date: 7_/ ----0--�
Building Official(or designe EMAIL 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
=tea!f.r 1 Congress Street,Suite 100
�l'Ec� Boston, MA 02114-2017
N,,,,t, www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print L-•'blv
Name (Business/Organization/Individual): ,-i N9�7 r7C-is
Address: S tvei Cr-oaf /'''
City/State/Zip: yar,,,,iy--4 y9,19 O?�c Phone#: Si)- 76e 2-2
Are you an employer?Check the appropriate box: Type of project(required):
1.pi am a employer with / employees(full and/or part-time).* 7. ❑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.]
3.0I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9 ❑Demolition
4.01 am a homeowner and will be hiring contractors to conduct all work on my property. I will
I0[j Building addition
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
5.0I 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?
6.0we are a corporation and its officers have exercised their right of exemption per MGL c.
14.❑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: e 4/4
Policy#or Self-ins.Lie.#: 6 S S S v e O 2 2 41 i 7'7?3 Expiration Date: -3?<97 21
Job Site Address: Z l 4 S p ) !'S 1 lh City/State/Zip: Y417,1e2-7)71XD?&
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 the and penalties of perjury that the information provided above is true and correct.
Signature: Date: 11/
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#:
Keating Construction AiHome improvement contractor registration: DATE April 13, 2023
143053
Quotation# 1
54 Lower Brook Rd
So. Yarmouth MA 02664
Phone(508)760 2702
timkeating66@hotmail.com
Proposal for: Job name/location:
Dave Self€ Same
27A Springer Ln
Yarmouth Ma 02664
We hearby submit specificatons and
Strip roof shingles off entire house except back flat roof
Install water and ice shield on lower edges and chimneys
Install new vent pipe flanges and 30 lb tar paper on decking
Install new 8 inch white drip edge
Install Certainteed Landmark 30 yr architectural shingles
Remove rake boards on front middle roof rake
Replace with Azek Trim
All debris and trash will be removed and disposed of property
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. $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: $6,750.00
Senior Citizens discount included
1/3 payment due at start of job and remainder upon completion
Acceptance of Proposal: Date of acceptance: y/17/A 3
Acceptance of Proposal: _ Date of acceptance: et `/�( L 7
The above prices, specifications and conditions are satisfactory and are hereby accepted.
Al + I) m►T€pwNODr+mr)CERTIFICATE OF LIABILITY INSURANCE 03n7r23
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holler is an ADDITIONAL INSURED,the policylles)must have ADDITIONAL INSURED provisions or be endorsed.
if SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain Policies may require an endorsement. A statement on
this certificate does not confer rights to the certificate holder in lieu of such enn�orsement(s).
he
PRODUCER Etilh: PAUL SCHLEGEL
Schlegel&Schlegel Ins Broker PNaNNEa Ems: 503 771^ 1 I VA,Not: 508-771.0663
[AMC,
34 Main Street ?J4.Ss: schlegelinsurance@gmaii.com
West Yarmouth,MA 02673 ILSURER(S)AFFORDING COVERAGE NAIC S
INSURER A: MOUNT VERNON
INSURED SNSURER B: CNA
TIMOTHY KEATING DBA KEATING INSURER C:
CONSTRUCTION INSURER D:
54 LOWER BROOK RD INSURER E
SOUTH YARMOUTH,MA 02664
INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER-.
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR NE POLICY PERIOD
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 ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
MR 1 POLICY EFF POLICY EXP LIMITS
LTR TYPE OF INSURANCE peso YID_ POLICY NUMBER AM10DNYYY) (MNYDONY1(Y) ((
XI COAMAERCIALGENERAL LIABI,nY EACH OCCURRENCE 1$ 1,000,000
DAMAGE TO RENTED
1 vi ,-REM;SSiS(C.a mac; 500,000
-MED EXP(Any are person) $ 1m,000
A NN 12325470 03/19/23 03/19124 ,PERSONAL&ADV INJURY $ 1,000,000 CLANs�tADe )^i taccuR 1
GENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
POLICY 1 JECT L�
[-�1 PRO- PRODUCTS-COMP/OP AGG $ 2,000,000
$
OTHER: - - C=OrABINED SffJGLE LIMIT
AUTOMOBILE LIABILITY r=---
ANY AUTO BODILY INJURY(Per person) b
OWNED SCHEDULED BODILY INJURY(Per accident) $
HIRED ONLY AUTOS PROPERTY DAMAGE S
HIRED —� NON-OWNED ON (Peraccdere)
AUTOS ONLY AUTOS ONLY S
I UMBRELLA UAB —OCCUR ,EACH OCCURRENCE S
EXCESS FLNAB CLAIMS-MADE AGGREGATE y$
IDED I I RETENTIONS S
WORMERS COMPENSATION I MUTE 1 i 1 ERR
AND EMPLOYERS'LIABILITY YIN 1 OO,ODO
ANY PROPRIETORMARTNERIEXECUTIVE E.L.EACH ACCIDENT $
B RN OFFICEREMBER EXCLUDED? N N i A 6S59UB0224N37223 03/09/23 03/09/24 E L DISEASE-EA EMPLOYEE $ 100,000
V yes, a describeery rim 500,000
DESCRIPTION
IPTI under E.L.DISEASE-POLICY LIMIT $DESf.7i1PTION OF OPERATIONS below -
IH I 1 i
DESCRIPTION OF OPERATIONS(LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is required)
TIMOTHY KEATING HAS ELECTED TO BE COVERED UNDER HIS CURRENT WORKERS COMPENSATION POLICY
INSURANCE COVERAGE IS LIMITED TO THE TERMS,CONDITIONS,EXCLUSIONS AND OTHER LIMITATIONS AND ENDORSEMENTS OF THE
POLICY
I
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
TOWN OF YARMOUTH
BUILDING DEPARTMENT YARMOUTH MA AUTHORIZED RE PRESEN1
Atvs
cs
I ®1988-2015 ACORD CORPORATION. All rights reserved.
ArnRJ)75 r2n1a/01? The ACORD name and logo are registered marks of ACORD
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