HomeMy WebLinkAboutBLD-19-1786 MMCCARTHY CONSTRUCTION CO.
RECEIVED
NOV 07 2018
MMC Date: i J � ' BUILDING DEPARTMENT
By
mj mccarthyconst@gnail.
cornBuilding Commissioner
Building Department
PO Box 52 YAeat'w Jtti 13t —19 —wi 7? V�_
West Dennis,Ma n'1 A SS i-� b
02670
To whom it may concern,
This affidavit is to certify that all work completed for Permit
Location: LC—HISS 10$ /V f f{it.) SC 0 241R-.5—
Has
6 5Has been Inspected by a certified Building Performance Institute(BPI) inspector. All
work performed meets or exceed Federal and State requirements.
Sincerely yours,
Icha�
C
L Office Use Only
n 11
Ammmt
B Permit expires 180,days from
/
sue date
. EXPRESS BUILDING PERMIT APPLICAT � E I V E I)
TOWN OF YARMOUTH i
Yarmouth Building Department SEP 25 2018
1146 Route 28N
South Yarmouth, MA 02664 Y " —
�`c( (508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS: ) 0c( �i:n 9. 5< f7..'-
ASSESSOR'S INFORMATION: •
1 Map: Parcel: Q
OWNER �c I I c,,, 5---0..5---0...._. i ^ )375---,0I
NAE Mike Maglii410DIEtiustruction TEL. #
•
CONTRACTOR: PO Box 52
/ NAME West N.elmus.r>M s 02670 ,.#
6Residential ❑Commerci Cell (508) 280-6964 oo
CSL-58633 HIC-1( 3Y3ofconstuctionS /(
Home Improvement Contractor Lia# Construction Supervisor Lic.#
Workman's Compensation Insurance: (check one)
❑ I am the homeowner 0 I am the sole proprietor %/ave 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 Sr' 0J CSP.
Laudon of Facility
I declare under penalties of perjury th. . . men,/here, .ntained are true and correct to the best of my knowledge and belief I understand that any else answer(s)
will be just cause for denial or revs ;. ,,I. ay Tic. a +.dor prosecution under M.G.L Ch.268,Section I.
Applicant's Siglature: �/ c Date: l I3'Sd l s'
Owners Signa 1 (or attachm n Date: /y a
Approved By: ie�> f Date: / 26-/
8(trma1(or designee EMAIL RISS:
Zoning District
Historical District ❑ Yes ❑ No Flood Plain Zone: 0 Yes ❑ No
Water Resource Protection District: Within 100 ft.of Wetlands: '
0 Yes 0 No 0 Yes 0 No
SO 5 3. 1S RloC
DocuSign Envelope ID:157DCA1D-9EB9-4C10-8312-3DDBB30A50D3 / I
Celt — ci S7>Sfas I"1 I/ a-- clg
Cape Light SF — 9$ i-s N. ju-2-4
Compact
5 Dupont Avenue South Yarmouth, MA 02664
n , a r
OWNER AUTHORIZATION FORM
I, PAUL LEWIS
(Owner's Name)
owner of the property located at:
108 Main Street
(Street)
Yarmouthport, MA 02675
(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.
,D000sigow by:
Pout Ll wis
`beet €nature
6/27/2018 112:40 PM EDT
-Sign Date
06/19/2018
Lrk (Qo4n49?ow,evect,44 ciai.wackt-seta
4- a17il=a .
s I Vii' Office of Consumer Affairs and Business Regulation
•
10 Park Plaza- Suite 5170
Boston, M-c��-.:* usetts 02116
•
Home Improve ;4'... ...,-tractor Registration
1
•
Type: Individual
MICHAEL MCCARTHY Registration: 169393
P.O.BOX 52 "1 � '=~ Expiration: 04/1512019
WEST DENNIS,MA 02670 ,M — --_
teF i �/
ll •
Ir„Cl...,., y7• S`P`
•
Update Address and return card. Mark reason for change.•
SCA.' 8 20M-05.11
_.----_ __ _..—.Ti Addr.e. Ti RAn.wal fl Empieymant r7 Lost Card
C9ommonwea4t(i oiOwaaa
s dadsld
40.
Office of ConsumerAffairs A Business Regulation
mm rJ HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only
'* moi - i TYPE:Individual before the expiration date, if found return to:
r* , �1egiltratioq Expiration Office of Consumer Affairs and Business Regulation
-:-f]695193 OW15/2019 10 Park Plaza-Suite 5170
ICHAEL MCCABt y_.-'i''• Boston,MA 110
„/L ,
:W 4:::44:1
.r.:.yd
•
MICHAEL F.MCC¢RT: ';;r',.:
BRANOLEYLN. ••io',k.C.•,I•
SOUTH DENNIS,MA 02680 Undersecretary Not valid without signature
r • r„I ,®� Commonwealth of Massachusetts
Dfvisfon of ProfessionatLk:ensure
•
•
• Michael McCarthy 11
Board o/auilding Regulations and Standards
McCarthy Construction ConstructitSrj rbUpervisor
CS-058833 • ,•
Has suceaish,ly Completed ttte National Fiber' v m ' ,' Eypires;04/10/2020 `
Cellulose Training Course .
1 231d day of August 2011 MICHAEL JA/00 ARTtiy •:.r • -
PO BOX 62 i �
WEST DENNIS MA 028 , C`
WNW,Naaolla Pant NW tr:/1�43,-"~� ' r
i DireateNotnlfa mss NATIONAL� nain ^ O n ,.„.
�+« � Commissioner lcir ,/��
1.O3 illuree _._. _
OSHA 001558712 . ., o ' "` :� .,
r °�•�R ilt d •Y4 _
a ae�a5eyyi,� X
,`.1! Siiiwo.lf Pall Ctminataa 4
U.S.Department a Labor 4..
Occupational Safety and H881111 Atlmottratbn .!r •-tr 21 ..
Michael McCarthypeeerreaf
�/�
has successfully completed a 10-hour Ccuyatblu i Safety and Health Crew �� h.
e a Safety
T Course h' • Cowne ^
Training - as Flown of ClanTimund a houauffield time ;;•'` 'r`
Constr iO.Safety d Health . ., o+A..,,
JXrJ7] ' .9/9/07' '1.f - u's--- i---44.-•--.7—.. ' ..Y• '
(T (Data) -
,.---
__ The Commonwealth of Massachusetts
'i Department ojlnditraMal.le idents
•
_;,�_ 1 CongressStroet�Salte100
-•a:'= ; Boston,MA 02114-1017
=l'' wwxtmassgotl/dla • .
Workers'Compensation Insurance/Affidavit Ba mtPlumbere
TO BE FILED WITH THE PERMITTING AUTHORITY.
&ScantInformatien Please Print Leeibly
Address: . Q•Ck Ger S
City//State/Zip: Wc)e- Qn'.•y /''l/4- QM '-Phone#: szt -140trtti
Are you se mpleye t MS th hest Type of prefect(regolred):
I.Ell.emaemployer ebb eo@Ioysee(NtlStar paWtlme).• T. ❑New coostitxdon
y.❑Iennob meteor orp.te paodlavesomployweworths brute In 5. ❑Remodeling •
.wn*.No its'eon.St ruqtd.J 9. Demolition❑
• Somme*b.❑I am a Somme*ddns sA watt myself NO waken'amp.inseam!caldron.]t 10 0 ti addition
4.❑I an homeowner and will behiring contractors to conduct ell Work m my property. IwN
snore ent all aaohmmn either have workers'co pmwtlm instunts ar am sole I I.❑Electrical repairs or additions
••proprietors with ao employees. IT.❑Plumbing repairs or additions
da I em arm)tonmamcr end I have bleed the adtomwton listed mea attached sheet l3.❑Roof repairs
Then mbemtreooahaw employees haemployees and ban works?comp.Seance .
•
6.❑Weare asotpommimditsofcershaveerentaddmkrf�ofexeepaanpsrMOta 14.❑Other
In;6l(4),and mire no employees.No workea'comp.insurance required.)
'Any rppeaurtthatchednboxIN must also Aa out the section below showbig their workers'compensation policy ham. •.
t ampawwenwho submit this affidavit Micotios they we dolma all wort and then hire outside contractors must submit anew affidavit Indicating such.
tpoohaosatathat check this boa most attached anadd/demi sheet showing the came orae sob mmawmra sad nate whetter or not those enddes have
employees. Ifineeob•oonhsdas have employees,they mat provide their weans'emP policy vomiter.
lam an eiqWqer Met 1I am an employer thee h providing workers'eelgn taationaaarrancefiraryemplojees. Below Is the policy aSJob eke
inlbraadon. A
Insurance Company Name: /V.Lh•..•.4 Lf4.itt+„ e--..91f'•'Yc 1�.s
+ .
Policy#of Setf--unto.Lic.#:_Ji...) C7•i 7r7 Y / Expiration Date: I)I,sr 1 t g
Job Site Address; City/State/Zip:
Attach a copy of the wokers'eompeoaatiori policy declaration page(ahtrerheg the Oleg somber mad expiration date).
Failure to secure coverage as required under MOL c.1S2,125A Is a criminal violation punishable by a free up to$1,500.00
and/or one-year imprisonment,as well as civil penalties in the brut 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 tbrwarded to the Office of Investigations of the DIA flx Insurance ;
coverage verifcedon. .
Idohereby artily wafer/w/ ,, o°^ ala7that tie halbrmadonprovided above trawe and correct
4�/ if
r
phime#: (RA)An-C.Tat( .
Official use only. Do not write In this area,to be completed by city or town offklaA
Qty or Town: Pennit/License 0 .
•
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
.6.Other '
Contact Petton: Phone#:
r
4.„..-----•••1MCCART9 OP ID.T
tAi o CERTIFICATE OF LIABILITY INSURANCE DATE(MMDDYYYy)
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 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 two' Dennis Office
NAME:
Bryden&Sullivan Ins Agency PHONE 508-398-6060 FAx 508-394.2267
Df Dennis Inc.
(Ac,No,Ext
I(NC,No):
485 Route 134,PO Box 1497 I'Doaiss:
So.Dennis,MA 02660
Bryden&Sullivan insurance INSURERS]AFFORDING COVERAGE NAIC P _
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 ADDL SUBR POLICY EFF POLICY EXP
LTRINCO wvo POLICY NUMBER IMMIDD/YYYYI (MMIDD/YYYYI LIMITS
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $
CLAIMS-MADE n OCCUR DAMAGE TO RENTED
PREMISES(Fa occurrence] E
—
MED EXP(Any one person) $ _
—
PERSONAL a ADV INJURY $
GEML AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $
POLICY n j ef 0 LOC PRODUCTS-COMP/OP AGG $ _
OTHER. $
AUTOMOBILE LIABILITY (Ea
COMBINED SINGLE LIMIT $
— ANY AUTO BODILY INJURY(Per person) $ _
AUTOS •— SCHEDULED BODILY INJURY(Per accident) E
_ OWNED ONLY CDEp PPq HTyyp
AUTOS ONLY _ AUTOS ONLY (Perr aaadenIQAMAGE E
E
UMBRELLA UAB _ OCCUR EACH OCCURRENCE $
EXCESS DAB CLAIMS-MADE AGGREGATE $
DEO RETENTION$ $
A WORKERS
ND EMPLOYERS'COMPENSATION
X STATUTE FOR H-
V9WC747574 12/15/2017 12/15/2018 EL EACH ACCIDENT $
ANY PROPRIETOR EXCLUDED? IY(l 1,000,000
QFFICEtoty In E E%CLUDEOT Y N/A
,elantlatory In NN� E L.DISEASE•EA EMPLOYEES 1,000,000
N yes,describe der 1,000,000
DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Addltlonl Remarks Schedule,may be attached If more 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
ACORD 25(2016/03) ®1988-2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD