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Home My WebLink AboutBLD-19-000698 A E Office Use Only _' T-. s ''�& ! e.Permit# C _ . 1 /� $ AmmmL _ � ,�Z. _ �Permit expires 180 days from . --- s=-�r, issue date atb4q -d�r°1 � R E C E'-,1 E D EXPRESS BUILDING PERMIT APPLICA I TOWN OF YARMOUTH AUr, 0 3 2018 I Yarmouth Building Department 1146 Route 28 Buii '715:.3T— /jr Br South Yarmouth, MA 02664 ( T(508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 9 S I STred - cue ASSESSOR'S INFORMATION: Map: Parcel: OWNER C� r\+I.vt PIt..c.. / 5.aL Gl7 -t77-07(f NAM Mih fr y Construction TEL # • PO Box 52 CONTRACTOR: NAME y gasmy, MA 02670 Cell (508) 280-6964 rEL# ,dential 0 Commercial CSL-58633 �etion S /SOD Home Improvement Contractor Lie.# Construction Supervisor Lie.# Workman's Compensation Insurance: (check one) ❑ I am the homeowner 0 I am the sole proprietor have Worker's Compensation Insurance - Insurance Company Name: Worker's Comp.Policy# WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation 1./ Old Kings Highway/Historic Dist ( )Replacing like for like Pool fencing 'The debris will be disposed of at Sift «Co Location of Facility I declare under penalties of perjury that the stat en.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 . e a • n• prosecution under MGL Ch.268,Section 1. `' Applicant's Signature: J Date: kith/1' Owners Signatu. (or attachme t) / .-.1 Date: i Approved By. ri 44.' Date: a �C Air Buitdin_ :, or d r r EMAIL ADDRESS: Zoning District Historical District 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: • 0 Yes 0 No 0 Yes 0 No DocuSIgn Envelope ID:0E061081-CA33-4D73-AFF0-607D7DED5B09 8-19- Cam,light -':. Compact 5 Dupont Avenue South Yarmouth, MA 02664 C£'t1 — I0,s2- S`&' @ torr rt - 3� .'u 'a DQ OWNER AUTHORIZATION FORM I, Cynthia A Mancini (Owner's Name) owner of the property located at: 45 Taft Road (Street) West Yarmouth, MA 02673 (Town, State,Zip) hereby authorize (Subcontractor) an authorized subcontractor for RISE Engineering,to act on my behalf to obtain a building permit and to perform work on my property. This form is only valid with a signed contract. The Permit will be secured by the insulation contractor, at no additional cost It is the homeowner's responsibility to close out this permit by contacting their municipality at the completion of this work. �D cusiged q: u erSignature 5/8/201819:46 AM EDT -Sign Date 05/08/2018 _, l./ L Wynol� c/o D� i e f e t, au size at{sell, Office of Consumer Affairs and Business Regulation • °' 10 Park Plaza- Suite 5170 Boston,M. usetts 02116 Home Improve ;. tractor Registration Type: IndvWust MICHAEL MCCARTHY _ — Registration: 169393 P.O.BOX 52 "; �- _ - Expiration: 06/1512019 WEST DENNIS,MA 02670 F Y �a, S�PI Update Address and return card. Mark reason for change. SCA 1 0 20M-M.V11 -'---' — -- _ �,11 Addnetw r1 Rwnwtwwt rl Employment 11I oat Card Cil s Wornmonwerrt/e cybazsCadrreeaa 1. Office of Consumer Maks&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only Tit,' TYPE:Individual before the expiration date. 6 found return to: kegiatratlon Exnlrallotn Office of Consumer Affairs end Business Regulation -..,•-•:;11169,393 06/152019 10 Park Place-Sults 6170 MICHAEL MCCA{17f�_'-I,•- .;-,'' Boston,MA 116 g______ ers-if MICHAEL F.MCCt. ,,!...i ..:I. 6RANGLEYLN. '?a;„:„ .. (� r SOUTH DENNIS,MA 02660 Undersecretary Not valid without signature - - - ,®t Commonweakh of Massachusetts ,pR•P1 Division oif Professional Licensure • Michael McCarthy • Board of Building Regulations and Standards McCarthy Construction Constrrtttldfll$urvisor CS-058633 Has successfully Completed the National Fiber' r,'' e spires:04/10/2020 Cellulose Twining Course • � q ro,A I 23rd day of August 2011 MICHAEL J MCCARTHy. ' PO BOX 62 ' , WEST DENNIS MA 02670'6, ``� t 1, lips .y` WNW Naeons Abet N� �'13� •" a- ft/Canut NATIONALw � Plain 1 ^ Q �•L,. Wor ssadrmfra.emoow "'-"-'"- Commissioner /�//�- e _ t.dTl le ton,ru`n P �'T-.e-- .z"Qi � OSHA 001558712 • t . "eaa"s°�`"i �...:..is., �: . fanbeaus safrp/erew 'aW p U.S.Departmem of labor , i%3= ` C}ef trrhTivaas t•_ Occupational Safety and Health Administration .`. - Vy�- -,� 4 ` % Michael McCarthy gr(pFge[ x , Crew 8- u818d 0°PIM1o88,etambNM .} Chiehas aureossfully completed a 10-hour Occupational Safety and Health t^8 a0anboedoo Safety ;�, Training Course . Cane In se Roma ofoauIlmeand 8 boon affleld time ,`n''• ( --,4 Constns on Safely 6 Health • I ocen a cen,,„,e ,�' ff . . - 9/9/07 • ---4.14-.-.141%,......,•r- .i 69 • The Commonwealth ofMassachasetts ty = •i Department oflndastrial4agldenes 1 ConigressSweet*SrdteIN Bostpn,MA02114-2017 wmttmasrgo►>/dta • Workers'Compensation Insurance Affidavit eetridaus/Plumbera TO BE FILED WITH THE PERMITTING AUTHORITY. hgpieant Information Please Print Leeihiv Name p /1 ..LI ) 1 tM7.. C... t.. t.c Address: ' Q.G. Bar S o City/$tatelZ(p: wc,?- an,., M/4- 0)-(7-phone#: szt —3010 trete Are you ea employer?Checkpppwpelen box: Type of Prot(required): l.�•amaemployer wtb employees(aramdSpaodtrel• 7. 0New cons&uction 2.01warokpeopdemrorp aterahipzed nevem arayloyeeawaddle ThoneIn B. 0Remodeling ' any apdty.[No aldose comp.boumee ngebed'1 al 9. 0 DenaBtion is 1 ma homaawmt dole{an work myself[No workers'mum.Insurance rpotred.1 t l0 0 Building addition •4.0I an ahomeownermad w0 be hMeg eotosmes n conduct as isoek on me'property.Iwai .more that ail teenactors either have waked commetoatlen insurance or see sole 11.0 Electrical repairs or additions , ••pmprietm wit m employees. 12.0Plumbing repairs or additions SC 1 ern a general contractor and 1 have hired the autaeantractots Med on the attached sheet 13.❑Roof repairs Thesembcomnomn have employes.and have makers'amp.Instance d.0 We ereacotpaadao Sits ofReets have exenkedthakright ofexempdeeme ism n. 14.0lkher •i 152,il(4),end wehave noemployees.[No wodme'ooem.bursae nmahr ) •Any,ppllcezd tint checks box fl mutt also CU cut the action below Stowing theirwodmte compeundoepolicy inMmaom. • t Rompownen who Meth this affithaft Indicating they are dohm A work and then biro molds contrataroots tanewatadavitIndieWngsuck tCbnaaomn that cheek this box east attached an additional sheet Swing the tome of the enbeuc motom ad ambwhetheror at mom entitles have employees• nut mintautadorl have employees.May au provide their mats'crop.poky number. Jam an employer that Is providing workers'compensation besnrancef re my employees. Below Is the pang andjob site leo Insurance company Name: /\1.b.,..., La-6.tal. �.S9 1�'��S 17...f. Expiration Date: 11 r t Policy#or Sdf ins.Lie.#:� 5 v1 G7'1 7�7 Y P I 91 Job Site Address. City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the pagcy number and expiration date) ••• Failure to secure coverage as required under MOL c.152,425A Is a criminal violationptmishable by a fine up to$1,500.00 • and/or one-year imprisonment,as well as civil penalties in the them of a STOP WORK ORDER end a fine of up to$250.00 a day against the violator.A copy oft is statement may be forwarded to the Office of Inveatgatiom of the DIA for Insurance . coverage verification. . Ida hereby care underth rofperfury that the lryamatkmprovided above trtrue end correct I r ;Mature: Date: /Ls/0 Phbne#: estik) n CT6ei • • • Official use only. Do not write In this area,to be completed by city or town official ` Permit/License# City or Town: Issuing Authority(circle one): 1.Bard of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#: • • • r MCCART9 OP ID.TP- A.CC: F4CO CERTIFICATE OF LIABILITY INSURANCE 003/01/201 YY) 03101/2018 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 holder Is an ADDITIONAL INSURED,the policy(les)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 508-398-6060 C%N�ACT Dennis Office N M : Bryden&Sullivan Ins Agency PHONE ( c,No,Em):508-398.6060 FAX 508.394.2267of Dennis Inc. (SIC, Nay 485 Route 134,PO Box 1497 Miss: So.Dennis,MA 02660 Bryden&Sullivan Insurance INSURER(SI AFFORDING COVERAGE NAIC F INSURER A:National Liability&Fire Ins INSURED Micha Box el McCarthy Construction INSURER B; POWest Dennis,MA 02670 INSURER C: INSURER D 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. ILTR TYPE OF INSURANCE O SUBR POLICY NUMBER (MM,pYPYEYnD POLICYEXP LIMITS 1lrMmDY COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE _ S CLAIMS-MADE OCCUR DAMAGE fEa occurrence) $ MED EXP(Any one person) $ —_ PERSONAL a ADV INJURY $ GGEEIML AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE I R _ POLICY WI: O LOC ,PRODUCTS-COMP/OP AGOJ OTHER' $ AUTOMOBILE LIABILITY (Fe COMBINED LIMIT ANY AUTO BODILY INJURY(Per person) $ _ OWNED SCHEDULED BODILY INJURY(Per accident) f _ _ AUTOS ONLY CIT.�Opp pppp HTyy pp — AUTOS ONLY _ AUTOS ONLY (Para cident)AMAGE f _ UMBRELLA UAB _ OCCUR EACH OCCURRENCE f EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEO RETENTION$ $ A WORKERS POYCOMPENSATION RS'LIABI�LITNY X STATUTE FORTH- Y9WC747574 12/15/2017 12/15/2018 E.L EACH ACCIDENT S ANY PROPRIETOR EXCLUDED? PROPRIETOR/PARTNER/EXECUTIVE 1,000,000 (Mandat EnNH)EXCLUDED? Y N/A 1,000,000 1 sndsk I N EL,DISEASE-EA EMPLOYEE $ N yes,describe OF O DESCRIPTION OF OPERATIONS below , E L DISEASE-POI ICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS(LOCATIONS I VEHICLES(ACORD 101,Addmenal Remarks Schedule,may be attached If mon space Is required) Michael McCarthy,President,has opted to exclude himself for Workers Compensation benefits CERTIFICATE HOLDER CANCELLATION CAPELIG SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Cape Light Compact Box 427 Barnstable,MA 02630 AUTHORIZED REPRESENTATIVE Kkaith,1 G A b 0a ACORD 25(2016/03) C 1958.2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD .