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HomeMy WebLinkAboutBLDX-26-118 4< yA E — R 1 I Office Use Only 411i6 C; w Permit#f— X l'«g I FEB i g 2026 Amounts --. P �. EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: Li e C./4p `1 1 Ii(J.�1 Y 41/M 6 v W.t. "Ad 6 2 6,ry OWNER: j A V€ L ,' 41 01 NAME '1�� �' PRESENT ADDRESS TEL. i? ,n CONTRACTOR: ' , ire4D1/1 I- 2s5 St/ P i" �R11 P j Y4.l 11 ` A 15 NAME MAILING ADDRESS L.#t 34 c' ?to-7 Z EMAIL: -1 i M/-144 f-' (u,kr/04c,-( < 0 I'r _ vZ� Residential ❑Commercial L Est.Cost of Construction$ 1 7)5 C)C) Homeowner is Applicant? Yes No Home Improvement Contractor Lic.# (`l3'a-J}' Construction Supervisor Lic.# WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate required) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares 2 7 Insulation Temporary Mobile Home Temporary Construction Trailer Demolition—Interior only *Demolition Raze Structure Solar System ESS System Chimney Fence *Please submit utility disconnect letters for electric&gas-structures over 75 years old require historical review 'The debris will be disposed of at: `h4 0 L1+ Location of Facility I declare under penalties of penury that the statements herein contained are true and correct to the best of my knowledge and belief. 1 understand that any false answeris) will be just cause for denial or revocation of my 'cense and for prosecution under M.G.L.Ch.268,Section I. Applicant's Signature. Date. Z/3/C Owners Signature(or attachment) Date: Approved By: Date: Building Official(at designee) Rev 6/24 The Commonwealth of Massachusetts Department of Industrial Accidents y Office of Investigations ' Lafayette City Center 2 Avenue de Lafayette, Boston,MA 02111-1750 www mass.gov/dia Workers'Compensation insurance Affidavit: Builders/Contrastors/Electricians/Phumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): ---rir-)?/f e,04 1-th5 Address: 5t1 LUgoe-i City/State/Zi 4(m v,)% 414 Of615. Phone#:3'&- 76e.-2'749 Z Are you an empto er?Check the appropriate box: Type of project(required): 1.1j I am a employer with 1 4. 0 I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. 0 New construction 2.0 I am a sole proprietor or partner- listed on the attached sheet. 7. Ea Remodeling ship and have no employees These sub-contractors have 8. 0 Demolition working for me in any capacity. employees and have workers' 9[No workers' comp. insurance comp. insurance.; El Building addition rP� required.] 5. We are a corporation and its 10.0 Electrical repairs or additions 3.0 I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.]'' c. 152,§1(4),and we have no employees. [No workers' 13.0 Other comp. insurance required.] Any applicant that checks box til must also fill out the section below showing their worke 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 mployees. if the sub-contractors have employees,they must provide their workers'comp.policy number. am an employer that is providing corkers'compensation insurance for my employee&. Below is the policy and job site nformation. ,/ asurance Company Name: C,/4 olicy#or Self-ins. Lic.#: D 7 7 L/Ai 3 72. Expiration Date: 3/5/Z �)b Site Address: `7 Z G v'� egi(,A417 City/State/Zip: t. C,/'{IL u G 62 > .ttach a copy of the workers' compensation policy declaration page(showing the policy n mber and expiration date). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ne up to S1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER.and a fine F up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of ivestigations of the DIA for insurance coverage verification. do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct. gnature: Date: tone#: i Official use only. Do not write in this area,to be completed by city or town official 1I City or Town: Permit/License# Issuing Authority(check one): 10Board of Health 20 Building Department 31:City/Town Clerk 4.0 Electrical Inspector 5Ek'lumbing Inspector 6.0Other Contact Person: Phone#: Keating Construction f E ; Home improvement contractor registration: DATE November 17,2025 143053 Quotation# 1 54 Lower Brook Rd So.Yarmouth MA Phone(508)760 2702 timkeating664hotmail corn Proposal for: * Job name/location: Deb Lamothe 4- R.V Same 42 Captain Blount Rd South Yarmouth Ma 02664 We hearby submit specificatons and Description Strip roof shingles off entire house Install Certainteed ice+water shield on all lower edges Install Certainteed Roof Runner Paper Install new vent pipe flanges and 8 inch white drip edge Install Certainteed Landmark 30 yr architectural shingles Install ridge vent on entire peaks Install rubber roof on back flat deck Install Azek rake boards and returns plus tear down chimney and plywood in 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$17,600.00 1/3 deposit due at start of job Acceptance of Proposal. Date of acceptance: , 2.- (49 Acceptance of Proposal: Date of acceptance: The above prices,specifications and conditions are satisfactory and are hereby accepted. THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs and Business Regulation 1000 Washingto . ret- Suite 710 Boston, Massachusetts 02118 Home Improvement COntractor Registration z „. a Type: Individual TIMOTHY KEATING Registration: 143053 • D/B/A KEATING CONSTRUCTION 1 ` Expiration: 06/13/2026 54 LOWER BROOK:RD. � _ SO.YARMOUTH, MA 02664 � ' Update Address and Return Card. THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs&Business Regulation Registration valid for individual use only before the HOME IMPROVEMENT CONTRACTOR expiration date. If found return to: TYPE:ndividuai Office of Consumer Affairs and Business Regulation EggistrattS n Explratior. 1000 Washington Street -Suite 710 ',4305S 08/13/2026 Boston,MA 02118 TIMOTHY KEATING D/B/A KEATING CONSTRUC.IOON •t TIMOTHY B.KEATING 54 LOWER BROOK RD. t SO.YARMOUTH,MA 026134, — Undersecretary Not valid without signature Commonwealth of Massachusetts Construction Supervisor Specialty 17 Division of Occupational Licensure Board of Building Regulations and Standards Restricted to: Constructs Ci f�liylr Specialty CSSL -Roofing i.SSL-W=riiS-ifir'mdows and Siding CSSL-099351 i' cpires:05/11/2026 TIM B KEATI G = 54 LOWER 94 o J z" SOUTH VAR Utri aYO#L�d�J�o Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. Commissioner _S.....1_6444,.�._ Contact OPSt:(tit7)7Z7-3200 or visit www.mass.govldpilopsi ......--wq,Io TIMOTHYK01 AREGULA A c R© CERTIFICATE OF LIABILITY INSURANCE f DA 3/6/2M/D25 ITHIS 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 holder is an ADDITIONAL INSURED,the policy(ies)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 endorsement(s). PRODUCER CONTACT NAME: World Insurance Associates,LLC i PHONE E»/:(508)771$381 1 FAX,No):(508)7'.'1-0663 34 Main St. West Yarmouth,MA 02673 ['Mal _ INSURERISI AFFURIANta GOVERAUE 4 NNi.i I INSURER A:Nautilus Insurance Company_ (17370 riibUR€G i INSURER B:Continentai Casualty Company 20443.--._-__-- TIMOTHY KEATING DBA KEATING CONST L INSURER C:_ _ 1 54 LOWER BROOK RD NSURER D SOUTH YARMOUTH,MA 02664 1 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. NSR ADDL SUER ^ POLICY EFF I POLICY EXP LTR l TYPE OF INSURANCE I NSD VND POLICY NUMBER i IMM/DDNYYYI IMMIDONTYYI LIMITS A I X COMMERCIAL GENERAL LIABILITY I EACH OCCURRENCE ,$ 1,000,000 ! I CLAIMS MADE X OCCUR NN1675006 3/19/2024 3/19/2025 DPREMISES tEaEoaurrea e) I$ 50,000 MED EXP(Any one person) 1$ 5'000 PERSONAL&ADV INJURY 1$ GEN'L AGGREGATE LIMIT APPLIES PER: I GENERAL AGGREGATE 1$ 2'000 000I POLICY j LOC PRODUCTS.COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABLITY COMBINED acci SINGLE LIMIT $ ANY AUTO 1 BODILY INJURY(Perperson) $ OWNED SCHEDULED I AUTOS ONLY1 r `AUTOS ! BODILY INJURY/Per sc det t$ AUTOS ONLY 1 AUTOS ONLY ! �Pe�a cRide t4AMAGE 3 $ EXCESS LIAR auAIMS-MAREI EACH OCCURRENCE I$UMBRELLA LIAB i OCCUR --_--- AGGREGATE 4 a � I 1 DED RETENTIONS I B WfIRKERS COMPENSATION T I Y I PER ' ' OTH- I$ AND EMPLOYERS'LIABILITY Y I N F ` I STATUTE ' I ER ANY PROPRIETOR/PARTNER/EXECUTIVE _ ,, 0224N372 3/9/2025 3/9/2026 E.L.EACH ACCIDENT i $ 100,000 FFICER/MEMBER EXCLUDED? i N '41/A ((Mansstary le: Hj 100,000 E.L.DISEASE-EAEMPLUYEEI$ If yes,describe under 500,000I DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT I$ I I Ii I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more spy is required) INSURANCF COVFRAGF IS I IMITFi1 TO THE TERMS,CONnITIONS,FXCI LIMNS,OTHER 1_IMITATIONS ANO Fy17ORSEMFNTS OF THE POI ICY CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Ca Symphony THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 2235 Iyannough RD West Barnstable,MA 02668 AUTHORIZED REPRESENTATIVE i / v w ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. 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