HomeMy WebLinkAboutBLD-19-696 -o _Office Use Only
$-
• ' Permit#
O heal ..; ^9- Amount �S
7
BPermitrtes
exp' 180 days from
issue data
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EXPRESS BUILDING PERMIT APPLICATIO
TOWN OF YARMOUTH RECEIVED
Yarmouth Building Department
1146 Route 28 AU6 03 2018
South Yarmouth,MA 02664
(508) 398-2231 Ext. 1261ui F , ; ,{
,1 --`3 //,;NT
CONSTRUCTION ADDRESS: 1-kr^1C r> a„ IL ASSESSOR'S INFORMATION: •
Map: Parcel:
OWNER: C>_k-c�� ii .. 5""` &s .l—")o -3Cc7
NAME M;1kepretetC1artsa;:sConstructlon TEL. #
•
CONTRACTOR: PO Box 52
NAM,g WitalipdfotkrsiVIA 02670 TEL#
Cell (508) 280-6964
esidential ❑Commercial CSL-58633 HI(93!$ SChm$ /Co
Home Improvement Contractor Lic.# Construction Supervisor Lic.#
Workman's Compensation Insurance: (check one)
❑ I am the homeowner 0 I am the sole proprietor OSI 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 ✓
Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing
"The debris will be disposed of at $ L ewe,
Location of Facility
I declare under penalties of perjury that the statemen s h., in 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 1'y� ...f...m cation under M.G.L.Ch.268,Section 1.
Applicant's Si:. Date: kb/h
Owners Si; attire(or attac en i i— Date:
t.
Approved By: 1 4/ Dale: !/ Ty/
Building ,:.•.ee) EMAIL ADDRESS:
Zoning District
Historical District 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No
Water Resource Protection District: Within 100 R of Wetlands:
0 Yes 0 No 0 Yes 0 No
. - ?v\ 790 3L,
r
•
A't . ni 5 Dupont Avenue South Yarmouth, MA 02664
CVRI SE
.ENGINEERING S{
«S sir
CEtk - up-s-Sd& 9 " 2'33
OWNER AUTHORIZATION FORM
I, CATHERINE ELLIS
(Owners Name)
owner of the property located at:
4 Homers Dock Road
(Street)
Yarmouth, MA 02675
(Town, State, Zip)
hereby authorize 0000
(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.h
-Customer Signature
i— ? C - /�
-Sign Date
01/08/2018
_I =---.4=
= a �stxc 2usell�
rig--. Office of Consumer Affairs and Business Regulation
10 Park Plaza- Suite 5170
•
Boston, M usetts 02116
Home Improve tractor Registration •
_� Type IntBvkfual
•
MICHAEL MCCARTHY �_ 7 1 Registration: 169393
P.O.BOX 52 Expiration: OSH5J2019
WEST DENNIS,MA 02670 .,
'ff. / ,
•
Update Address and return card. Mark reason for change.
SCA 1 0 20M-05/11
"'---"'"" --' __ _.__.I-1 Arldrees f1 Renewal rl Fmploymant h Lost Card
Ce2e 9Pontenonwea`!/r c/ auac%rrds43
Office of ConsumerAffairs&Business Regulation
V
HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only
TYPE:indMdual before the expiration data If found return to:
heplltraton 06/15/pkpirationOffice of Consumer Affairs and Business Regulation
=f 18993 06/i5/2019 10 Park Plaza-Sults 5170
MCCA69101'• , Boston,MA 116e_____ ,
.. tici,i
MICHAEL F.MCC1gTa i4 ;:' _ Y
,per
B RANGLEYLN. •i0.s::;•,r'
SOUTH DENNIS,MA 02860 Undersecretary Not valid without signature
•
�„ ,®� ,Commonwealth of Massaehusetts
,mss DWision of Professional Licensure
Michael McCarthy ® Board of Building Regulations and Standards
•
McCarthy Construction Constr.,C t6ri 1$ifPervisor
•
CS-058833 n •
Hes sUCC.SS uily Completed the National Fiber' EIC fres;04/10/2020
Cellulose Training Course ,": �'
ra MIC ;#LkF ? ,;_ .
•
' ��1. 23 day Of August 2011 PO aHOAEX 62 ; J _ .
i
��=� , WEST DENNIS MA 0267, s�
�SSWades - NATIONAL Plant ^ e �f/ir
1 Notre l an NWeMed ""-""^ • - /L�' a/M.- `ia+
Commissioner
r 1..olnnu.....,.r, 11
OSHA 0015587 2 ; _ . ;. ..... . ., ;'
i�� a 5L,
.yr ,.,wr+ serrd..
U.S.Department w Labor C 6aktoitrrie Ckirf Catalans' ' 1'
•
Occupational Safety and Health admu sua bntr
* T.
Michael McCarthyVitirfalig •y
neew eadreo yel.eelae oa+a�lwnvsarey,�dHnnn O"' �sSoceessfullyCompletin1heb�"
Combustion Safety
Training Coins n 3a awlewa.a'mmand 96ouaaflleld time
a'
I C nsbv 'on Safety a Health « _ '
. MI Y
7�' 9/9/07 °t` •
1' f•
TheeCommonwealth.�//.� �).o�f�A)laas�a�c�hJu�se/l�la
1 Ell =,qt Department of Infastr aI4cch eats
Tagil
1 CorgressSbrer SAke100
' =•'i°- ;' Bostor4MA02114-2017
- 6rwtsme�amt/d!s •
Workers'Compensation Insurance Affidavit edrldans/Plombera.
TO BE FILED WITH THE PERMHTIINO AUTHORITY.
Askant Information
/ Please Print Legibly
Name (� mel): / 'htl.,�( 11
t $71 C.., a.. re,
Address: ' P•C)' 10 S 2.
1
City/�tatetZip: Ws.?- an's•y M 4- Ont-Phone#: C -.J -0701,
Are you N iiapIewrt Chad boa: Type of project(required):
l,[ifamampbyerwith *splayed*WIandkrpatedme}' 7. ❑New coasthcdon
1❑ramatebproprietor ccpatunblpend ban soemployees waling firms b 8. ❑Remodeling .
anynpdq. Nowadcua'comp.insure=required] et
9. ❑Demolition
2.01 ash a h®eowsa debt an wart myselfwe(No ice camp.Imam=acted.]t• 16❑ ti addition
4.❑4.01am aheeteowtte and will he hiring connectors to conduct dl iill
conduverk on try property. I w
enema that an contemn either have senate empemegm imams cram sole 11.0 Electrical repairs or additions
propdam with co employees. 12.0 Plumbing repairs or additions
5 1 am a rowel contranarad I brie hked to aa5.coosmmn Itemd an the attached sheet. 13.❑R.00f repairs
These ad ore have a:oployeea and have workers'comp.immco t ur .
•
6.0 We an aeeryontmnn
aodioffcershaaremhMdtheir:ightofasanpdospeaMM20La 14.00ther
152.f!Mend we have no employees.No waken'comp.Smuts tom]
*Amy applicant lint St haS!net also fill out the sector below towing their workers'component*policy Information. •.
t gompowoaa who admit this aadmitlndining they we doing an work and sen hire outside mammon mon submit snee affidavit indicating such.
tconmaoton that chedi this box man attacked es additional sheet thawing S name of the Sconwmmm and state'Anthem oat thhose entities have
employees Utile anbccouanas have employees,they twist proud.their warked romp.policy meddler.
lam a n employer that is providing workers'compensation bran►ancelbr ray employees. Below is the policy and Job eke
In broaden.
Insurance Company Name: /V" •—I L&b.114s...9 icer -C4.4.
Policy It oiSelf-ins.Lie.Si: J1v., C7'I'75-7 L/ Expiration Date: Il lbs i IR
Job Site Address; Cl4' ip:
Attach a copy of the workers'compensationi policy dedaratloa page(showing the polls j camber and expiration date). •.
Failure to secure coverage as required under MOL c.152,125A is a eaiminal violation punishable by a fine up to$1,500.00
and/or one-year imprisonment,as well as civil penalties in the but 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 boarded to the Office of Investigations of the DIA for Insurance
coverage verification. .
I de hereby care ands tis ; , i of perry dsadthe hybnaadon provided*bore it amend correct
• / / i" r
a-' ? e
phiaie#: (6bt'>lo-C.n.a(
Official ase on(p. Do not write to this area,to be completed by c14'or ben o,QftdaL
City or Town: PernNHlle ense ft .
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
'6.Other '
Contact Pehon: Phone#:
r
J/ MCCART9 OP ID:TI,
ACOROr DATE(MWDO/YYYY)
CERTIFICATE OF LIABILITY INSURANCE 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(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 508-398-6060 hair Dennis Office
Bryden 8 Sullivan Ins Agency PHONE 508-398-6060 I FAx
508-394.2267
of Dennis Inc.4
(Ate,No,Ext): (AIC,Ne):
So.Deunnis MA 02660x 1497 ADDRESS:
Bryden&Sullivan Insurance INSURERS)AFFORDING COVERAGE NAIL s
INSURER A:National Liability&Fire Ins
INSURED Michael McCarthy Construction INSURER B:
PO Box 52
West Dennis,MA 02670 INSURER C:
INSURER 0:
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.
INSR TYPE OF INSURANCE iN o SUBR POLICY NUMBER POIDDrYY EFF POLICY EXP
fMOLIC YE (POLICY EXP , LIMITS
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 5 _
CLAIMS-MADE ❑OCCUR PRA AG O RISES RENNTTE eel S
MED EXP(Any one Demon) S
—
PERSONAL S ADV INJURY S
GEM.AGGREGATE LIMITpoAPPLIES PER: GENERAL AGGREGATE $
POLICY O JEL'T O LOC PRODUCTS-COMP/OP AGO S _
OTHER S
AUTOMOBILE LIABILITY (FO s acciNdentSINGLE LIMIT) S
— ANY AUTO BODILY INJURY(Per person) S _
AUgT�O�S ONLY _ SCHEDULED
AUTOS pBppOpDILY INJURYNJrypp (Per accident) $
AUTOS ONLY _ ORM War azRdent)AMAGE S
S
— UMBRELLA LAB — OCCUR EACH OCCURRENCE S —
EXCESS LAB CLAIMS-MADE AGGREGATE S
DED RETENTION S S
A WORKERS
EMPLOYERS'LLIABILLIITNY X STATUTE FRTM
ANY PROPRIETOR/PARTNER/EXECUTIVE V9WC747574 12/15/2017 12/15/2018 1,000,000
E L EACH ACCIDENT S
(Ma duos MBER EXCLUDED?
Y NIA EL DISEASE-EA EMPLOYEE S
1Ir�A ory�fn NN) 1,000,000
If yea,desalbeunder 1,000,000
DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT S
DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If mom apace le 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
Cape Light Compact ACCORDANCE WITH THE POLICY PROVISIONS.
Box 427
Barnstable,MA 02630 AUTHORIZED REPRESENTATIVE
ACORD 25(2016/03) OD 1988-2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD