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HomeMy WebLinkAboutBLD-19-002759 Y 3 Office Use Only ' > ..•:.s 4ir; ! rt) kFarah* c o i� : SAmrnmt �� Permitires 180 edays from - �issue date x-49-00 7 RECEIVED ; EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH NOV 06 2018 Yarmouth Building Department 1146Route 28 Bui I = DEPART E!• South Yarmouth, MA 02664 av: ` (508) 398-2231 Ext. 1261 • CONSTRUCTION ADDRESS: 1 Sek6lc LCh L j^ (v A ASSESSOR'S INFORMATION: • Map: Parcel: OWNER CZ.n.7 CIL, 5.rt ct77d'i NAME Mike MEWAR1113Priinstruction TEL if CONTRACTOR: PO Box 52 NAME West filit#MisgUMst 02670 TEL if SLI sidential ❑Commercial Cell (508) 280-69 4 of Construction S ' Ge CSL-58633 HIC-133 Home Improvement Contractor Lie.# Construction Supervisor Lie.# • Workman's Compensation Insurance: (check one) — 0 I am the homeowner ❑ I am the sole proprietor Q4 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/fiistoric Dist. ( )Replacing like for like Pool fencing 'The debris will be disposed of at J"1 cs(co Location of Facility I declare under penalties of perjury that the eats 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 revoc e an prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: III C /1 Owners Signature(or attachment) Date: Approved By: � .4- Date: 1\ ' ) Building Official(or des ce) 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 04. RISEN ENGINEERING S� _ I t S‘c 12_, 2— OWNER AUTHORIZATION FORM 1, David Cirillo (Owner's Name) owner of the property located at: 1 Stable Lane _ (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 27 \-C 2a f g Date RISE Engineering,a Division of Thielsch Engineering, Inc. 5 Dupont Avenue I South Yarmouth, MA 02664 l 508-568-1926 www.RISEengineering.com 1 // �P ec /o1 l J �l� Q9�UJ�ZOOZL(1 Q ig_ sfxc tcJel i jr Office of Consumer Affairs and Business Regulation 10 Park Plaza-Suite 5170 • Boston, usetts 02116 • Home Improve Registration I--;:– — ^,,• Type: Individual MICHAEL MCCARTHY .— Registration: 169393 P.O.BOX 52 i e:-..l .;` = Expiration: oensr1019 WEST DENNIS,MA 02670 ,2. ..-----. : . _Ei — • 1/4r 50• Update Address and return card. Mark reason for change, WCA1 0 2041-0v11 -- ____...�.11 Addrn.t r,Renewal rl Pavlov/non! Li Lnattard s9 s%ommranmea/Orn o`B4aaaadtweella 1' DMMoe of Comma Affairs a Business Regulation V „ HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only TYPE:indMdualbefore the expiration date. E found return to - Office of Consumer Attain and Business Regulation 169 93 06/16/201910 Park Plaza•Suite 6170 MICHAEL MCCARTH�{' `' Y "• Boston,MA 116 MICHAEL F M e , tel!: gip.,, SOUTH DENNIS,MA 02880 Undersecretary Not valid without signature • 'CI ,®� rrvrtonweakhofMassachusetts ision of Professional Lkensure • Michael McCarthy Board::Building Regulations and Standards McCarthtructi Y Cons On Cons;r{iGitdd'$jrppervisor ' Has sueeassiuily Completed the National Fiber' CS-0586334.;:- ,f fres: Cellulose Training Course • ;t� • X �� 04/10/2020 , 21'ddsyofAugWt2011 MICHAELJMCCARUA Jt./ PO BOX 62 >. 4 :: WEST TENNIS M C.. -4 A,028 WNW Naiad near• IN 'r-h\'f 1�''�` • w/ I„ 4.--- OltrAtsral les NATIONAL Pleas "•"^ ' CommissionerNefna/rmaaMossi .. t_Onlrlue>wuvI OSHA 001558712r�.ra :..t:. .. US.Department of labor < a asa�� widcai�.. • Occupational Safety and Health AdministrationLil t•. r Michael McCarthy :: aat-1 sme,durbro. ��amrrotenaalwweoxunatwrwsaie<yandHanh ��4•s,iaai,s�as.iiy �: t a2R0000rrJ z.,eandahauRereddalM e'i' 7. Safety 6 Health ,. r t ;. oaHr.,a.,,e,.,e • 9/9/07 .. -w; ' • . . A _ a TheDeprtoentcommp/Naati. offrd aMsofMahasaclsse tr laatdats„ __— sn' 1 GegrssttSAt100 - Boston,MA 02114-2017 • Wooers'Compensation Insurance Affidavit TO BE FILED WITH THE PTRMITffig0 AUTHORITY. Skint Information Plane Print LevPoly • Namep: flag..( PC.--417 a- t.. t Address: . 9,G,.cr get. . S2 I City/$tate/Zip: 'Jc - an..., Mi$- O3(7-Phone#: rot -).40 -Ctrs, Are you on spicier!CheekBs.a rn ate bet T)'M dried(required): l,dimarployrwkh S ettpbyse(adlend/orpetdiir4• 7. QNew const action I.fll wise*proprietor r0e6rai*and have no employees wading tbrtot hi S. 0 Remodeling • any spotty.tato wmime coop.benne,regdr e J et 9. 6 bemohhion ID1ant ahameownrdoherell work melt(No ocelots'amp.hwmmrewired]t lOpButldfogadditimr '4.Qmr temahsmwcandwNbeMing onto doodad eahunkoomarpopetty.Iwi0 gimme tit all eaa ten either have wadme'mepeo.ouoo imams or are sole 11.0 Sledded repairs or additions ”pephka:UM m empbyees. 12.[]Plwnbing repa(n or addidom l4:1lememoral ormaaorend Ihave Wad th.nal ontreatora lisod on the attachedsewt 13.0Roofrepain flea odoeonaoore baro employee and have wodmrr'cmp.Imr®ae t • e.0Weeaeapraamwaamarsdibtuenen ed�Irdghtofem�mperldaa• l4.0Otber n 152,Ha end we hero no employees No workers'amp.bon= *Any update thus cheeks box elmoot ahotmant the elatlmbelowSwkgthdrwrlaao pmedmpotby •• tRompowmnwho'dude thle sineseit ladiestire goy ere dorm A wchand then lire odd&mouton meet Suit a new Okla*bdiewths nath. oboe re that teak this hot most attached an Elated duet showing the on&the enbwattietore ud uneweetheror Roo tban enthito have ..bent Mho nb n have employees,dry mit provide their wakes'tout pdoyrant Ins ens npleper titre isproviding wearers'omapassation tnammteelbr iv aaployeea. Below h the potty end Job site Insurance Company Name: /l/-11..,..1 1-4-61447 n.S gyre .114-.1. Policy#oiSof-ins.Lin.4:_ 1 ioJ C:711 51 4Expiration Date: 14,s-I t¢j Iob Site Address. CileStatefZip: Attach a copy of the workers'eompe Batton policy declaration page(showing the number and expiration oak). •. Failure to secure coverage as required under MOI.c.152,f 25A is a criminal viohtionpunishable bye fine up to$1,500.00 • and/or Imo year bnprisonment,as well as evil penalties in the tbrm oft STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be tbewarded to the Office of tnveatigatione otihe DIA for insurance coverage verifloadm. . Ido hereby ate soda rofperdwy fist the ig heretadonFolddabove is hal tied awed Sign: Dai: LLr 117 Official use ore. Do not reefs hr oda area,robecompleted byeeryorPoen t _ City or Torre: peen tillaase II Issuing Authority(circle one): 1.Bead of Heath 2.Building Department 3.Qtyffown Clerk 4.Electrical Inspector S.Plumbing Inspector d.Other Contact Person: Phone It: • r ' • MCCART9 OP ID.T A,CORO' DATE(MMIDDf'YYY) `„� CERTIFICATE OF LIABILITY INSURANCE 03/01n016 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 DennisgiaiecT Office Bryden&Sullivan ins Agency PHONE 508-398.6060508-394-2267 ofDennis Inc. (AIC,No,Eat): I FAx (AIC,No): 485 Route 194,PO Box 1497D''b`A'�sa• So.Dennis,MA 02660 Bryden&Sullivan insurance INSURER(S)AFFORDING COVERAGE NAICC INSURER A:National Liability&Fire Ins INSURED Michael McCarthy Construction INSURER B; PO Box 52 West Dennis,MA 02670 INSURER C: INSURER D: INSURER!: 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. II TR TYPE OF INADDL SURANCE AD Wvo POLICY NUMBER POLICY EFF POLICY EXP J IMOLIC YEFF lMMND(YJ(P LIMITS COMMERCIAL GENERAL LABILITY EACH OCCURRENCE S CLAIMS-MADE n OCCUR PRERIIGET RENT Denrel S . MED EXP(My one person) $ PERSONALS ADV INJURY S GE 'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S _ POLICY u j u LOG PRODUCTS-COMP/OP AGO S OTHER $ AUTOMOBILE LABILITY (Fa a idem SINGLE LIMBti ANY AUTO BODILY INJURY(Per person) $ _ AUTOS ONLY _ SCHEDULED SSyUyLNEEDD PBPgOqDILY INJURYTTy (Per e¢Ideni) I _ AUTOS ONLY _ AUTOS ONLY (Pent edentRGE S _ UMBRELLA LAB _ OCCUR EACH OCCURRENCE $ _ EXCESS LIAR CLAIMS-MADE AGGREGATE S DED I RETENTIONS S A WORKERS ND EMPLCOMPENSATION YERS NL ILII' X RTATVTE FR V9WC747574 12/15/2017 12/15/2018 E L EACH ACCIDENT S ANY PROPRIETORTARTNER/EXECUTNE 1,000,006 IFFICER/MEMg�q EXCLUDED? Y N/A (Mendelory In nnl EL DISEASE-EA EMPLOYEES 1,gDD,OOD M yea,&mate under DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY I IMT S 1,090,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached 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 AUTHORIZED REPRESENTATIVE Barnstable,MA 02630 1 n lA ACORD 25(2016/03) • ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD