HomeMy WebLinkAboutBLD-19-001784 MMCCARTHY CONSTRUCTION CO.
RECEIVED
L NOV 0 7 2018
MMC Date: if IS BUILDING DEPARTMENT
By
mJmccarthyconst@gnail.
corn Building Commissioner
Building Department
PO Box 52
West Dennis,Ma A'
02670
To whom it may concern,
This affidavit' to certify that all work completed for Permit OZ6�S
Location: �A0-0-r 2-0 ////t't 2 T Q4
Has been inspected by a certified Building Performance Institute(BPI)inspector. All
work performed meets or exceed Federal and State requirements.
Sincerely yours,
chael art.
O4..YgR @ Office Use Only
F
z; c _perm U! 5
i 3S� 4
o Iy`;4 nmo me ,
�RK
o rd R permit expires 180 days from
EXPRESS BUILDING PERMIT APPLICATI $
TOWN OF YARMOUTH SEP 25 2018
Yarmouth Building Department Bu NIT
1146 Route 28 av ���-1' �'�
South Yarmouth, MA 02664
(508)398-2231 Ext. 1261 •
CONSTRUCTION ADDRESS: )411(C.Irt.)1— Y y9... ,L
ASSESSOR'S INFORMATION:
nn 2 Map: Parcel:
l,
OWNER: —6..m 6r.N...01- S.., t 6n -6K '3707
NAME Mike Msgmthotalosti ua tion .may #
CONTRACTOR PO Box 52
NAME WCe �c36964� 02670
TEL,#
CYResidential ❑Commercial CSL-58633 HIC-162393Constuction$ ) Cbv
Home Improvement Contractor Lia# Construction Supervisor Lie.#
Workman's Compensation Insurance: (check one)
0 I am the homeowner 0 I am the sole proprietorhave 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 t/
Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing
'The debris will be disposed of at Srfr-S— Oct a
Location of Facility
I declare under penalties of perjury that th - .y3 ,ts h •. contained are Inc and correct to the best of my knowledge and belief I understand that any false answer(s)
will be just cause for denial or revo .. • rrtc•. 4 d for pros ;pounder M.G.L.Cb.268,Section L. C/
Applicant's Sigaanlre: i Date: // IF
wr
Owners Signore(or attachme,r - Date:
Approved By: G! Date: 7-2.5-7e
Building lel(o Ignee) EMAIL ADD 5:
Zoning District
Historical District ❑ Yes 0 No Flood Plain Zone: ❑ Yes ❑ No
Water Resource Protection District: Within 100 R of Wetlands:
0 Yes 0 No 0 Yes 0 No
(o 11 - torc, -3-; on-
\Wit QG,.o - I low se p z" y - %V 019.-A
RISE
ENGINEERING
OWNER AUTHORIZATION FORM
I, Barbara Brandt
(Owner's Name)
owner of the property located at:
20 Hillcrest Road
(Property Address)
Yarmouthport, MA 02675
(Property Address)
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.
Owner's Signature
g - i
Date
RISE Engineering,a Division of Thielsch Engineering, Inc.
5 Dupont Avenue I South Yarmouth, MA 02664 I 508-568-1926
www.RlSEengineering.com
. 29L �po n2, eaN a/v`/la facAc lea
11 Office of Consumer Affairs and Business Regulation •
Ai
10 Park Plaza- Suite 5170
•
Boston, M usetts 02116
•
Home Improvem ' tractor Registration
t
•
-;=.� ,_,�.7- Type: Individual
MICHAEL MCCARTHY _ Z.; Registration: 169393
P.O.BOX 52M "i —'4 ' '' Expiration: 06J15�po19
WEST DENNIS,MA 02670 ;• '- ,
1 1AI .T/? .
Update Address and return card. Mark reason for change.'
SCA1 C) 20M-05/11
'""'-""-'-' Fl Addra., rl Renewed 11 Fmnlnvrnant r7 Lost Card
1 �ei a W�r+onweolt'o�Caaaackae/A
Office of Consumer Affairs&Business Regulation
tt HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only
�„ - TYPE:IndMduaf before the expiration date. if found return to:
i .. f eajstration Excitation Office of Consumer Affairs and Business Regulation
-y imps 06/15/2019 10 Perk Plaza-Suis 5170
MICHAEL MCCAA7t "•I` `.'�..40-. Boston,MA 116
g„.... ,
..Laz , ,;(.nyi f1, .
MICHAEL F.MCCi Rl' ;3'A.P. g,g__
8 RANGLEYLN. •',WA:; (�2-Cah--
•
SOUTH DENNIS,MA 02660 Undersecretary Not valid without signature
I r :®l Commonwealth of Massachusetts
Division of Professional Lkensure
Michael McCarthy Board of Building Regulations and Standards
McCarthy•
Construction
Constr�ICfk,fl'Sapervisor
t Has successfully completed the National Fiber• ! CS-058833 i
Cellutoes Training Coutes
,,,:;111* , t fres;04/10/2020 ;
N MICHAEL 'i
r "i 23 day&August 2011 POBOX82 MCCA •
i ��= , WEST DENNIS MA 02670• cr
. • ttat,asaRaE tw N li:R�ir.l� ,
'
DInhcbsr atSerea - NATIONAL PICER 4i
Commissioner it��ie`e`a
leaf sometime.• 1�
OSHA 001558712 + igesol aitate, �=e}r aadas,�iew...Xr
.
re
s fealRrosabahblCreYC}d Cnej t, ,,.' , yl,.
U.S.Department of Labor a�
Occupational Safety and Health Administration ° .>`i ci t
Michael McCarthy �'"` y
has ms.'•Tefury completed 110fiaa Occupational Safetyand Health • Crew1°8Dd Ae0)maCnmbmtion Safety :t
Training Course In - _ ` 32 Room ofClauTimeaanda hours afield time.
Consbu Ion Seely&Health . .el ,Ind«a,..,,,aao A.
9/9/07 -MiI:M:w�. a;. .,;_.,
Rr (Date) :•l.«...._..•:-'::::
�, • t `✓ The Commonwealth of Massadtasetts
',-77.7=ft DepartmentofIndastdalAeetdesrb
1 Co aSdret�Sedts100
_ Boston,MA 02114-2017
/ wroncmass /dla
Workers'Compensation Insurance Affidavit ne/Plumben.
TO BE FILED WITH THE PEHMITlING AUTHORITY.
flint Information Please Print Leelblv
Name �at
p k� �t(....41.7
( C..7)v¢a/h.. T..e ;
Address: . Q.C. 15er 5.2.
City/Ptate/Zlp: Vic.,?- an.-t i14- 02-c7'-phone#: sits -,i0 trete
Me ye'as employer?ark bee Type OfptDject(required):
I.[' 64naaemployerwih employees MBend/or pttdme}e 7. 0New consteuction
10Isaas b proprietororpartnmahipandismnoemployaeawohing fbrmela , L ❑Remodeling .
eep
any eity.[No weston'comp.Insurance rwuhed.l 9. 0 Dsmolitlat
5s.Iemabmroanerdoles weetmyself[No waists'e� r.quktl]t• 10❑DemoliBuilding eaaitlen
e.❑Iama6 end will be liking eommoronmconduct NIworkoneb,property. Iwill
encore sat all cam=ester in,.workers'ear,enadan imumee arum sole I l.❑Settricel repairs or additions
proprietor"whit noemployeet 12.0 Plumbing repairs or additions
5.0Iame eceralcontactorendIInnsbindthesubeattactorsHet=onteemadadSet 13OReofrepairs
Them moon bays employees end have workers'comp.Immmrmt .
•
6.0 We ere mendlofwomshtnoaobedthir right )4.❑Other
n
152.I1(0,rod we We no employees.[No wean'pup.him=mga(md.]
'Any smiler tat checks box 1/1 meet also fill out the section below showing teirworken'com peuesdon poecybfinmtlon.
•
tNampowoenwho rimatbden=Indianian ley an doing all work sod then likeoutside cremators one=maanewalfdtvkSiatingouch.
tcmtdctors Mat check this bon num maobed en edditanl sheet Swing=one et tbe subcontractors sad ate whetwor not those=him have
employees. If dosubeoonaomnsaveemployers,tnymwtprovide their workersrs'comp.policy number.
lant anemployer that Isproviding workers'compensation besmwscefbru employees. Below it the policy ariJob site
bibmwiden.
Insurance Company Name: AA-b.... l 1-6-6i 14), s..59 rm �lt.s.
Policy#or Sdf-int Lie.#:_t)5 W C7`i 7S7'I Expiration Date: I)J,c 1 i ft _
Job Site Address; City/Slate/Zip:
Attach a copy of the worker'compensation policy declaration page(showbiz the potlej amber and expiration date).
Failure to secure coverage as required under MOL c.152,1125A is a criminal violation punishable by a fine up to$1,500.00
and/or one-year hrgaisomnent,as well as civil penalties in the tbrm of STOP WORK ORDER end a fine of up to$250.00 t
day against the violator.A copy of this statement may be fbrwarded to the Office of Investigations of the DIA fix insurance
coverage verification. •.
I do hereby we underth es q/pedary thatt a Werneadonprovided*bore is true and correct
� ff r
Zinnias. Date: [Jr/s.7
phis ie#: (62k' o-C.U t( • '
Official ase on(µ Do not write in this area,to be completed by cloy or town offdal
City or Town: Permit/Lkense# .
Issuing Authority(circle one):
1.Bard of Health 2.Banding Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
•AOther '
Contact Pelson: Phone#:
r
MCCART9 OP ID:Ti-(
AMR'
Cr CERTIFICATE OF LIABILITY INSURANCE DATE 03/01/DDYYYY)
• 03/01/2018
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 pollcy(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 Par.!. Dennis Office
Bryden&Sullivan Ins Agency PHONE 508-394.2267
Of Dennis Inc. Luc,No,Eat): I 508-398-6060 FAz(Arc,Ne):
485 Route 134,PO Box 1497
So.Dennis,MA 02660
Bryden&Sullivan Insurance INSURERS)AFFORDING COVERAGE NAICS
INSURER A:National Liability&Fire Ins
INSURED Michael McCarthy Construction INSURERS:
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.
jI TR TYPE OF INSURANCE IINNSD SUBRL POLICY NUMBER POLICY EFF POLICY/DDSI
/MOLICYEFF f O/ EXP UNITS
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE
CLAIMS-MADE ❑OCCUR DAMAGE TO
(Eaoccurrence) S
MED EXP(Any one person) $ _
-PERSONAL&ADV INJURY S
GEML AGGREGATE LIMITAPPLIES PER: - GENERAL AGGREGATE $
POLICY El vs: n LOC PRODUCTS-COMP/OP AGO $
I OTHER
AUTOMOBILE LIABILITY COMBINEDSINGLE LIMIT easdentl
1
— ANY AUTO BODILY INJURY(Per person) $
OWNED SCHEDULED
_
AUTOS ONLY _ AUTOSBODILY
dnt1BODILY INJURY(Per accident) f
AUTOS
AUTOS ONLY — ONLY (Per acEcRDDAAGE S -
$
_ UMBRELLA UAB _ OCCUR EACH OCCURRENCE S
EXCESS LIAB CLAIMS-MADE AGGREGATE
DED RETENTIONS S
A AND EMPLOYERS'LIABILITYAIX STATUTE ERS
V9WC747574 12/15/2017 12/15/2018 EL :
ANY PROPRIETOR/PARTNER/EXECUTIVE 1,000,000
IpFFFICEIOIYEInNR EXOLUOEDT Y NIA
ff yes,
eA describe
eo l°NMI E DISEASE-EA EMPLOYEES 1,000,000
N s,dIPTION under 1,000,000
DESCRIPTION OF OPERATIONS below EL DISEASE-POLICYLIMr 5
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required)
Michael McCarthy,President,has opted to exclude himself for Workers
Compensation benefits
CERTIFICATEJIOLDER 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
I'LL -3r�
ACORD 25(2016/03) 01988-2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD