HomeMy WebLinkAboutBLD-19-001789 o4..y r,Office Use Only
3Z Wit; ! iC • -PermNt
G �t H' i Amount 3J ttyJ
s".' t Permit washes 180 days from
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Otal q-001/4 R . Y 0
EXPRESS BUILDING PERMIT APPLICAT I N
• TOWN OF YARMOUTH SEP 2 5 2018
Yarmouth Building Department BUS al , .P. . . . 4,
1146 Route 28 By: _ _ ' _js
South Yarmouth,MA 02664
1 (508) 398-2231nExt. 1261
CONSTRUCTION ADDRESS: 3 V�J. \-3-,,s_ )21- 5_,....a"(
ASSESSOR'S INFORMATION: •
Map: Parcel:
owNER: Skov; eSc4c.✓ S'.••._ 77 y-2Cd—Cc67
NAME PRESENT ADDRESS TEL. IS
CONTRACTOR
NAME Mike AftleinetWROmstructiort a#
residential 0 Commercial PO Box 52 Est Cost of Construction S 1`fa'
.West Dennis, MA 02670
. Home Improvement Contractor Lie.# Cell (5(1R ,og964ion Supervisor Lie.#
Workman's Compensation Insurance: (check one)CSL-58633 HIC.-169393
0 I am the homeowner 0 I am the sole proprietor IL,I4re 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 .1 1 CD4 t•
Location of Facility ,
I declare under penalties of perjury that the v.,em :.. ..,e'- coarced 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 .' ..y.. ..tat prosecution under MO.L a 268,Section 1..
/ l/( S
Applicant's Signature: Date: / 2S-I Ir
Owners Signature lerir .41r
Date:
Approved By: ��/�� Date: 9 2rV
Building Of a ' . or >!ee) EMAIL.ADD lig.
•
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
a;-3 £s— ,Oto
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DocuSign'Envelope ID:3F7DF2B8-603348D5-AADD•77906AE9AAEF
43 ✓Ak\1� — IleOS
RISE2C2�
n.-
v
ENGINEERING'
OWNER AUTHORIZATION FORM
1, Shari L Fecteau
(Owner's Name)
owner of the property located at:
38 Witchwood Road
(Property Address)
South Yarmouth, MA 02664
(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.
Docuely,nd by:
CS4 AL 4uaw
kr
351)IAYASF3I4CC
Owner's Signature
6/24/2018 I 3:41 PM EDT
Date
RISE Engineering,a Division of Thielsch Engineering,Inc.
5 Dupont Avenue South Yarmouth, MA 02664 1508-568-1926
www.RISEengineering.com
eh WO/Mni2Q/~eG Tal
- a afstac urea' •
/ An_
f Office of Consumer Affairs and Business Regulation
10 Park Plaza-Suite 5170 •
Boston, M usetts 02116
•
Home Improve tractor Registration
L
.,-,-...a--- — •_+ Type: Individual
MICHAELMCCAFTrHY Z' —~ Registration: 169393
P.O.BOX 52 :i E�4 .~ - Expiration: 06115/2019
M, .........
WEST DENNIS,MA 02670 _ - " ,
a sl
•
olhr SEPI
Update Address,and return card. Mark reason for change.
SCA1 0 20M-05/11
._,.___ �x QJ _.. _.n Actinism r'1 Renewal I'1 Emeym
plenr7 t Loat Cerd
9?. 1(�ommo wnaw4b(�./1bita,...2fl4et
Office of Consumer Affairs 6 Business Regulation
-` „�, HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only
yaI<. TYPE:IndMduSl before the expiration date. H found return to:
ftaaptratlo0 !ratio Office of Consumer Affairs and Business Regulation
•- -169393 Of515/2019 10 Park Plaza-Sults 5170
g '
MICHAEL MCCARTHIr., :_"-'_• Boston,MA 116
MICHAEL MCCZ
F RY. -; s' U '
6 RANGLEY LN. .r1.1.6.:-,
SOUTH DENNIS,MA 112610 Undersecretary Not valid without signature
' �; ,® Commonwealth of Massachusetts
D(v(ston of Professional Licensure
Michael McCarthy Board of Building Regulations and Standards
McCarthy Construction
Cons.... RjIS f$ePervisor
i CS-058833 .f'
Has successfully completed the National Fiber^ r -411‘
Fttoires:04/10/2020 ;
Cellulose Training Course ;,,ti , ;,
123ne day of August 2011 MICHAEL J ht'CCARTFiY� _ - -
/j PO BOX 6Y , p( "
�� V1fESi DENNIS MA 02870 �� 1M
iflhlrq Iama.w RMr •'1 r/h�-430-? x.',
dnoreraarr N •
.. .•a
NATIONALw ,. Pi OMR • ^ e
Na evMlmlreenWeaard Commissioner /CAL
Lou lit lleannn.. ] _
OSHA 001558712 ! °° -ti: :.+ `` "
a cane a Sektwoft QA QroYmteo ' $.
U.3.Deparlrtrom of Labor __
Oxllpetbnel Salary arW Health Atlminlelratbn
��LKe'Qd �`, •x
Michael McCarthy 7
•
- ��mmpledieg theCnmWgd -
huatxxessfutycompteted a t60ar Ocmgetbml Sarery and Hearn Qe^'mleri'euBdfeRAeelxTteCombmdee safe _+
Traintrq Corson 3a Rowe of Class Time ad8 hours afield time "
�� �Yr:�ZY. W Ion Safely 6 Hetlah - a Saar.,,.,.,
9/9/07 - - --- ^mane
s
, (Derr) .•.
'.) A_ The Commonwealth of Massachusetts
,,/i
y Department of IndustrialAce/dents
,o 1 Congress Steef4 Supe 100
_ Boston,MA 02114-2017
wlvMmasagovidla •
.— Workers'Compensation Insurance Affidavit •
TO BE FILED WITH THE PERMITflNG AUTHORITY.
Meant Intimation Please Print Legibly
Mune tie-Le.I 11t G
17 .. t.. r.,t
Address: ' QrCy gal. S2.
may/ gip: 1,..1c i Un-.•y M4- 01f7-phone#: rz4 -"Jo -Cr(s.
Are you nemployer?Check th hex: Type of project(required):
t.&l•rmaemployer wkh empbyeas(110 saw aenthsoY 7. ❑Newconstnxtton
2.1:11 am iens pmpdetorccpammMpand have noemploymermldoafin meIn I. ❑Remodeling .
no(ape*.pro wakens gyp•haemes requireg st
g, 0 Demolition
Claim knotloordoingelwatt myself(Nowakem'aomp.ioaonoere dredlt• lo❑Btdldingeddiden
4.❑I em a hemmer end will be Wring contractors m conduct ell iron win
on my property.1
ern*etilcontaaanettherhavewaken`compemafonSenn e or are sole 11.0 Eleclilcal repairss or additions
..poplins with no employees. l2.0Plumbing repairs or additions
CI I smarms contactor and I have liked the stScoutracten listed on dm attached sten 13.❑Rooftepairs
Thea subcontractors have employees and have worker(comp.thorn .
6.0 We an aeapaatlnadlootlle nbanexemkadtheirdshtofaten@thmperM to. 14.❑Otba •;
152,I%and we hon no employees.(No wake amp.Snaraagdmd•I
*Any spplicsiit dot chit box*1 must also on out the suction below showing their wetter(component."posey hdtmntlm. •.
tRorrpownerwhoeubmitthis'fadevhindicatingtheyemdoingailworkendthenhimoutddecontraemrsmudsubmitanewaffdaviti dicadngsuch.
knot/Store that neck this box moat attached an additional timet showing to name of the anbtattama end state shalom not Moa entitles have
employees. lithe d:•ennaaan have employees,they*mist provide thelr worker(const.ploy number.
I am an employer that Is providing workers'compensation i nsarencejbr sty employees. Below is the policy and job she
hi)braraden A '
fosureneeCompany Home: /v�d+..,..1 1-.4.6rl.,l, a�9 Y:7Nc -+•_.
1/4)5 vJ G71 7r7.1 Expiration Date: 11 jr,-I i$
Job Site Address. City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). ,
Failure to secure coverage as required under MOL c.152,42SA is a criminal vioWionpimisbable by a fine up to 56500.00
end/or one-year imprisonment,as well as civil penalties in the form of a STOP WORf.ORDER and a fine of up to$250.00 a '
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification. :
Ido hereby area ander rof palmy that the Information provided above is true end correct
r
giwa:dure: Date: /irk?
?thief!: eRsir An-C.Mt( • •
Official use onfj,. Do not write In this area,to be completed by city or town olfldal
City or Town: Permit/License SI .
Issuing Authority(circle one):
1.Boird of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector .
'6.Other
Contact Person: Phone SI:
r
..7.------"", •
MCCART9 OP ID:TF\
ALCORO' DATE(MM/DDIYYYY)
V. CERTIFICATE OF LIABILITY INSURANCE 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 WANED,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 192 geT Dennis Office
Bryden&Sullivan Ins Agency PHONE 508-398-6060 FAx 508-394.2267
of Dennis Inc. (A/C,No,Em): I(A/C.Na):
485 Route 134,PO Box 1497 iDogkss•
So.Dennis,MA 02660
Bryden&Sullivan Insurance INSURER(SI AFFORDING COVERAGE NAICf
INSURER A;National Liability&Fire Ins
INSURED Michael McCarthy Construction INSURER B:
PO Box 52
West 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.
INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP
ITRwico NMI POLICY NUMBER IMM/DDNWY1 IMMIDD/YYYYI LIMITS
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S
CLAIMS-MADE OCCUR DAMAGE
FS((FeE�encel $ _
._ MED EXP(MY one Demon) $ _
—
PERSONAL E ADV INJURY $
GENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S
-1 POLICY Tef 0 LOC PRODUCTS-COMP/OP AGO S
OTHER' S •
AUTOMOBILE LIABILITY (Ea
SINGLE LIMIT
(Ea amadent) $
— ANY AUTO BODILY INJURY(Per person) $
_ OWNED TOSS ONLY _ SCHEDULED
AUTOS
PBPgOqDILY INJURYTTypp (Per occident) $
_ AUTOS ONLY _ AOTOSONIY (PerOexident)AMAGE $ -
$
—
UMBRELLA UAB OCCUR EACH OCCURRENCE $
EXCESS LAB CLAIMS-MADE AGGREGATE $
DED RETENTIONS $
A ANDPLERNAIIRX MUTE EDP-
AND LIABILITY
ANY PROPRIETOR EXCLUDED?PROPRIETOR/PARTNER/EXECUTIVE Y/ V9WC747574 12/15/2017 12/15/2016 EL EACH ACCIDENT $ 1,000,000
(ManditOryIn E)EXCLUDED? Y NIA 1,000,000
1 andatory nNH EL.DISEASE-EA EMPLOYEE $
N m
a deebe under 1,000,000
DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT S
•
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
CERTIFICATE HOLDER CANCELLATION
CAPELIG I
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 AU1TNORRED/REPRESENTATIVE . /1
1A4 a
ACORD 25(2016/03) 01988-2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD