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Home My WebLink AboutBLDX-26-211 application og YA \ RECEIVED Office Use Only r/itPennitii K Qi c y' MAR 2 2026 1 N Amount �`ORPonn�Eo`b'9` BUILDING DEPARTMENT ey. EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508)398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 35 ShC P(e /4 Li 1( 0•,.? L y4f/yU k,f O Z67f OWNER: 50 D /f"'t C (6t + �-5 she/ 74.Pf,4, 144( 0 NAME PRESENT ADDRESS TEL. # CONTRACTOR: t ( (1 1C 1ey l r 41C S / L.Owe,- t/t/Mo)/► NAME MAILING ADDRESS TEL.#s0e.- 762 Z 1 EMAIL: �t 1't K(24-ti 45 40 PIOtw►4r'/ i C 004 ce Residential ❑Commercial L Est.Cost of Construction$ aid Homeowner is Applicant? Yes No—I Home Improvement Contractor Lic.# I t,' 3 OS) Construction Supervisor Lic.# ?7 -3-r WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate required) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares 1 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: \f Ct of/4 pivt 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 revocation of m license and for prosecution under M.G.L.Ch.268,Section I. j Applicant's Signature: Date: 31 23 / 2 Owners Signature(or attachment) Date: Approved By: Date: Building Official(or designee) Rev 6/24 I 5 5 3 , f g S . Y � S � �7� ,.~° The Commonwealth of Massachusetts Department of Industrial Accidents i , Office of Investigations ` ; Lafayette City Center A _ 2 Avenue de Lafayette, Boston,MA 02111-1750 `,,_;`�. WWW.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information /, Please Print Legibly Name (Business/Organization/Individual): f/h /C is +I et S Address: $Y L 0 i e. -gro,/- e,1 City/State/Zip: //ui 0 J'f 1, PO- Phone#: 50 77O Z7O Are you an employer?Check the appropriate box: Type of project(required): 111 I am a employer with i 4. 0 I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction listed on the attached sheet. 7. a Remodeling 2.❑ I am a sole proprietor or partner- ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp. insurance comp. insurance. required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ 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.]I. c. 152,§1(4),and we have no employees. [No workers' 13.0 Other 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. rr Insurance Company Name: C ,/f/s¢ Policy#or Self-ins. Lic.#: G 7 Z Lot,3 7- Expiration Date: 3/ S/Z' f-fa(!aw Job Site Address: 5�►�/7Rft�� S h City/State/Zip: D Z�'7J' Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that 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 ins and penalties of perjury that the information provided above is true and correct Signature: Date: _____ ? 3 Phone#: Sot 76v 2 9d 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(check one): 10Board of Health 20 Building Department 3tCity/Town Clerk 4.0 Electrical Inspector 50Plumbing Inspector 6.0Other Contact Person: Phone#: El >. '.; —';'-" " ..-.,'.,,,,,,,,,,,, ,.,.,.,„ , ,I ''.g- •,-- -' :- ''',,:•:-.:--„14'-q,.. ,:::,:„•- -'• ..:,,, , ,. _ , . . , ...,„,. ,, ,.„,, ,. ..i:„.. ....,„. : :. ..t.:.r,,.,.,..,,,.„, ,,,,,,,, ,,.. :::::: ,:,,,..,.:, ..; ,..�1„,„, _,,,s, :.. ::i.„..:,.,,., . ,,.. .. .p., ,,,.. , ,. ,..., , , , . „ . . , ,. iiiiimsois..,...„„.„„„„..4.:,..„.„,„„4„iv :r.,,,,,,,,,,.:„.,,..:,,,,,i,„„.;.... ..:„..„:::„.,,,,,,. :,..,,,...:,...„..„..,....,.;:.:: ,,. ...,,, ,.,,, ,... , .1, ..,,:, ,sititiorlauz.2030t,,),;:,,:7,,,!. .:,:.,:„.,. ..:,",....,,,I.T.,i.,!,., . „,.....,: ::: ,.,...:,...., . ..:.. :.,„:._r., pArs. moil,is,2024 it .� Kam, 7tS Y ,f , n ". , ... �-'4* " .� .le as 1 .% ..t ,•-i :. "a� .'m's �, �. tWIP �� ter ._' "-+ik k. �._ ,_ - - _•.w - .. '' + -- SAP^ ..•, .. _ Yt4` DAC . WORKERS COMPENSATION t-:-.:,,-;. crApigi . ANC EMPLOYERS LIABILITY POLICY pow me INFORMATION PAGE WC 00 00 01( A) POL NUMR: V9NA7-7-26) REISIIIIICY ALBE Ot► (6(d859S99t19-b3I6-bS4R]7-]-2 ) JRER: COWTX rrat. CASUALTY couture NCCI Co Cis 10243 A STOCK 1. INSURED: PRODUCER: IC Ty . KKR IBMWORLD INS ASSOCIAT!S LLC Ir i►T3R6 CONSTROCTIOB 34 MAIN STRa:T MA-28 se LOMNR **KOOK RD YA io 'R NA 02673 SO. x iiA 02664 Insuret*Is AN 31 )EVIDUAL Other Work plates and ration numbers are shown in the schedules)attached. 2. The poky period is tom'03-09-26 to 03-09-27 12:01 A.M.at the insered's mailin0 address. , _,,,,11,:,...!.: • 3. A. 1i COMPENSAnot RANCE: Part One of the policy applies to Workers Compensation Law of the states)listed here: °,i�. +OYER.S LIABILI Y NICE Part Taco of the policy applies to work in each state listed at st3.A. units ou lability under Part't�o ate:: by Accx $ x2 00 c Accident , Bodily - Y ' e: , a. 0000>�Employee C. ��'�1' ��1� Pst,"t`h o policy �the stat+e�s.��1►,listed ham: �All: ,1a ''_ + .$►s, os r � �i, x i: " lt>I' <�la"t1141�" � t� " deal by , s -tow . ,. fix. °" 4 �� a+ { �, Kw" i ,. w�a a t'..3y�e'y °i y 'Y,y� ` z Yti-. y , a, 3 `s 4' az y s -ate ,z T. '� ;', - .- i �^,.? r aw�'rz'emu,. S i,**N t' - „'%�rz �,'� o a "� ,u�: ��, !�n v,: _.te a As e, r,: i* ,. b .:: 6 t - n y vt�%4a 3 may, .141% °`v: Commonwealth of Massachusetts Construction Supervisor Specialty Division of Occupational Licensure Board of Building Regulations and Standards Restricted to: Constructs up tr Specialty CSSL-RF-Roofing CSSL-INS-Windows and Siding CSSL-099351 a; R I spires: 05/11/2026 TIM B KEATG u 54 LOWER O " SOUTH YAR �4 0 ,?b t,: p� `TOI.LVdiV) Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. Commissioner e s, Contact OPSI:(617)7273200 or visit www.mass.gov/dpl/opsi • THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affair'and Business Regulation 1000 Washingtc rt- Suite 710 Boston,_M sachusetts 02118 Home Improvement at's' ...or Registration f t Type: Individual 143053 TIMOTHY KEATING ` Expiration: 06/13/2026 D/B/A KEATING CONSTRUCTION V'"` 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: TYPEc"Individual Office of Consumer Affairs and Business Regulation Registration t° Expiration 1000 Washington Street -Suite 710 143053 "n 06/13/2026 Boston,MA 02118 TIMOTHY KEATING D/B/A KEATING CONSTRUCTION' ys TIMOTHY B.KEATING • 54 LOWER BROOK RD. .Y,t ' / LA- SO.YARMOUTH,MA 02664.;; Undersecretary Not valid without signature