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HomeMy WebLinkAboutBLD-19-002757 �t..y E Office Use Only Ar S .. ' •:. C, 8termite 3 5 .00', dr* !r .. L Amount --- rd' g Permit expires 180,days from - [issue date . EXPRESS BUILDING PERMIT APPLICATI11 C E) • TOWN OF YARMOUTH - Yarmouth Building Department I NOV 0 6 2018 1146 Route 28 South Yarmouth,MA 02664 Elulli B (508)n 398-2231 Ext. 1261 By �� = _ CONSTRUCTION ADDRESS: 31 1-7,$). Si-rc," Cis C,.}t\ ASSESSOR'S INFORMATION: • 1 Map: Parcel: OWNER 4 rh }�4— / 1 ` P.,,c,...0._ s.h stet - 0ft—ecirr NAME Mike Mctllrthyntl Srtruction TEL. # CONTRACTOR PO Box 52 NAME West AgPinias 02670 TEL.# Cell (508) 280-6964 ctsikl":sicleattal O CommercitSL-58633 BIC-16E9093 of construction$ 7�'" Home Improvement Contractor Lie.# Construction Supervisor Lie.# Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor (IA 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 'Mae debris will be disposed of at (S- cxc Location of Facility I declare under penalties of perjury that the .. n.herein contained re true and correct to the best of my Imowledge and belief I understand that any false answer(s) will be just cause for denial or revocati .. ..d for prosecution under M.G.L Ch.268,Section 1. Applicant's Signature: Date: II/C//! Owners Signature(or attachment) Date: 1 42 Approved By: „.77:::: Date: 11. 6- 12 Building Official(or designee) 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 C e)) - 3sj s4 / tZ- to } 5 Dupont Avenue South Yarmouth, MA 02664 R ENGINEERING OWNER AUTHORIZATION FORM I, ROBERT J MCDONOUGH _ _ , (Owner's Name) T Ai _ . , • Sner of the property located at: 34 Midstream Drive _ (Street) South Yarmouth, MA 02664 (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. 419 -Gusto e n ureA: Signe/dile 1/24/2018 Office of Consumer Affairs and Business Regulation • 10 Park Plaza-Suite 5170 • Boston, t�setfs 02116 Home Improve tractor Registration C! z, Type: 893idual 93 MICHAELmccARTHV 'T RegI6tralion: 06/15/2019 6/15/; 'i = 1 E>�Iration: 0 811 512 0 1 9 P.O.BOX 52 !-1 1 WEST DENNIS,MA 02670 - s 1 �, rpt••- lana; \\......"14 ^j' Update Address and return card. Mark reason for change. SCA 1 0 2011•05.11 —'----' - -_.._._•f1 A frlrses f1 Renewal f1 Fmeloymsnt ry I est Card CFAs 9raxsHonweala 901&asaaa4u tea. Ofaa of nsumerAffaln&Business ReguhuonVT- HOME IMPROVEMENT CONTRACTOR Registration valid for IndMdual use only TYPE:IndMdual before the elpfiration date. If found return to:t; Eaglmtlan Ofios of Consumer Attain and Business Regulation06/15/2019 10 Park Plate-Suite 6170 EL MCCA,RT} a 1' Boston,MA 11 ie. eze: .stir i r; MICHAEL F MO t R SOUTH DENNIS,MA 02660 UndersecretaryNot valid without signature CnvhonowePeroltheosf Massachusettsens-----®r DHo(slonnnassLacensure Stand ardsBoard of Building RegulsatoMichael McCarthy McCarthy Construction ConstruCtigritn rvisor Has successfully Completed the National Fifer^ 1 CS-058633 Cellulose Training Course f Fe3�ires:OM10/2020 25nday0tAugtial2011 MICHAEL J MICA r t POBOX62 ia?r , WEST DENNIS MA 026700 v.`" 7/ . . . .s 4r Her• - art 1,,r"T;yam '. ` �ederet a� mealcate t.FINER Commissioner 1ro1rmew,.blw. OSHA . 001558712 one& zw.,.ra ., .. rim. Calms eatsbJteafcod Cssrirnue uOccupational.awn .m a mlabor <l,; ` Occupational Safety end NHeathAdminaealbWaage n . Michael McCarthy y �+�c»arhramhwe tet surcesslurycmlpleteda Ulnas Occupational Safety and Health �'"�8i0dbaA idle eormhmd,u;suSy TMWq Cane ' 22 asmaorcla%ivm ehwnardaiddme 4 ! 7, Safely 6 HeaIM . _• i r. 1>nrax.,+•+In...r . ,. IV�iv...�W i YwK Jb'a' __ The Commonwealth of MassachaaaKa it_ a/ Depatimaaofl al4cctdasts - w t I CongressS/neer;Sake100 loabstgMA02114-2017 wwlttrsergal✓dls . Workers'Compensation Insurance Affidavit: TO BE FILED WITH THE flRMrtflN0 AUTHORITY. &Sant Information Please Print Lealbly' NamC /1,�.,� )1 1:-41.7 C... .. ret t Address: . 9•Cr gar du 5.2. 1 City/Pat/Zip: we - an.., N4- Oxy'-Phone#: rat -3k ,cuts, Ms you nemployer?Cheek"swamis bus Tfpeofproject(reguired): I.1femaemployer with employees(Mn atFeedmrl• 7. 0New coestmction 3.0irmeahpeptides orpvmaddpsod here memployes wadded* melde, S. ❑Remodeling • mye saky4OM*[Ho Mal tmilasdd 9. ❑Demolidm y.❑lsmiYn 000mrdolmen waitwv [No lead® map ' .kma nonp�d.lt• 9. 0Buiidiojtddition 4.1:II mahomeowner and will be Mosaotreomn to condom en int en my property. Iwill mows that an ecatmomrs either have watbn'eampmrnka baurec a em sale 11.0 Electrical repairs or additions '•prorMomwit maaptoyees. I2.0Phtmblagrepairs or additions yaIanametal mmeeot r and I have Ithed the submarereatanlistedmamattachedsham. 13.❑Rcofrepairs These abmomacOmaIlan employees sod has endues'omop.immmmt • e.❑weart acmpamedndisomanm hamdmdtheirtight&exeaptionperMOt.a l4.❑Otlter U7,ll(Q,ad wvhas so employees(No snore amp.bmmnaegdtad.) • •Ng"piked that chedmba til mom also III ret the nation below showing their sextets'co peantlm policyhtformstica• • •• tB....,- rns who saberdt this affidevit Mating theyerenounwakedtheahimamideaooenomamomsubmitspewetadavitbdlatlnpads. :Caddo=dot Sokthiboxmomsoothedntldltlmaldimsbowmaanasnotthesobmooteamaadatetetrmeatemuentldeshaw employees IUM auraamnmas hen employees,they mist provide their radon'romp.policy=bar. Ian en employer dist h previa:two:ken'compaisationbarance fir mg aftpbyees. Below Isthe magi arrSJobthe bljbrmodo a A Insurance Company Names / L.L.•.1 1.Ptij,t;{„ c..9 -htit et ,. Policy#bi Self-ins.Lie.4: J1 W C']•I lfl'-/ / Expiration Dale: 14 I t R Job Site Address; C 41 Attach a espy of the workers'compensation policy declaration page Perth/the peltej amber and expiration date). • Failure to secure coverage as required under MOL c.152,825A Is a aiminal violatknptmbbable by a floe op to 81,500.00 • end/at one-year imprisonment,as well u civil penalties in the lbrm of a STOP WORKORDER and a fine of up to 5250.00 a day against the violator.A copy of this statement may be tbswarded to the Of[ice offnvest(gatiom of the DIA Ott insurance coverage verification. . Idoherby way riderViW"ydunkslinpivnMddonIshireendament FMB= 1lem LIAt9 phone#: (stt)Ao-Knit( ' 10fitekd use orgy. Do mot suite be ebb area,to be completed by city en toed of fdaf : City or Town: Penult/License# Inning Authority(circle one): 1.Baird of Health 2.Building Department 3.City/fown Cleric 4.Electrical Inspector S.Plumbing Inspector . ti.Other Contact Pelson: Phone#: •r MCCART9 OP ID-TM 4•1C-0R0CERTIFICATE OF LIABILITY INSURANCE DATE(MM/03/01/22018018 ) 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 ktlecT Dennis Office Bryden&Sullivan Ins Agency PHONE 508398.6060FAX 508394-2267 (A/C, ro of Dennis Inc. (A ,Ne,EN): �(A ,No): 485 Route 134,PO Box 1497 FAon�ss: So.Dennis,MA 02660 • Bryden&Sullivan Insurance INSURER(S)AFFORDING COVERAGE NMC P INSURER A:National Liability&Fire Ins INSURED Michael McCarthy Construction mSUURER e: 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 AU.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 I TRMCD woo POLICY NUMBER JMM/DDNYYY1 IMMIDDWYYYI LIMITS COMMERCIAL GENERAL UABILTY EACH OCCURRENCE 1 CLAMS-MADEri OCCUR DAMAGE TO Feoomenel $ MED EXP(Arty one Person) F — PERSONAL S ADV INJURY $ _ GGEEINL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE• S _ I POLICY❑jpa LOC PRODUCTS-COMP/OP AGO S OTHER S AUTOMOBILE LIABILITY (Fe accNNEEDISINGLE LIMIT S — ANY AUTO BODILY INJURY(Per Person) $ OWNED SCHEDULED _ AUTOSg�� ONLY _ AUTOS SSWNED BODILYgqINJURYTy (Per accident) $ _ AUTOS ONLY _ AUTOS ONLY (Perr eEC,IIdenIRAGE $ S _ UMBRELLA LIAB _ OCCUR EACH OCCURRENCE S EXCESS LAB CLAIMS-MADE AGGREGATE S DED RETENTIONS S A WORKERS X MUTE ANMOYRS' ILTY V9WC747574 • 12/15/2017 12/15/2018 E L EACH ACCIDENT S pANFYPROPREIEIJT6ORIPARTNDED? THE 1,000,000 (MEnEP1 MN EXCLUDED? Y N/A 1,000,000 (M NN' E.I.DISEASE-EA EMPLOYEES If yes,describe under DESCRIPTION OF OPFRADONS below E L DISEASE-POI ICY I MIT 5 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,AddMenal Remarks Schedule,may be attached Mmol epee Is required) Michael McCarthy,President,has opted to exclude himself for Workers Compensation benefits • CERTIFICATE HOLDER CANCELLATION CAPELIG SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POUCY PROVISIONS. Cape Light Compact Box 427 AUTHORIZED REPRESENTATIVE Barnstable,MA 02630 • ( lJillakcjiez ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD