HomeMy WebLinkAboutBLD-19-002985 �, A e Office Use Only J
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11
EXPRESS BUILDING PERMIT APPLICATI S E C V E D
TOWN OF YARMOUTH NOV 14 2018
Yarmouth Building Department c
1146 Route 28 ) 3 L( DE PA
South Yarmouth, MA 02664 • nr
(508) 398-2231 Ext. 1261 I
CONSTRUCTION ADDRESS: 51 A b II $ een�/t- U_'t 3)—
ASSESSOR'S INFORMATION: .
Map: 1 7 Parcel: 9
OWNER rt✓tli 1:2601tr RRFFSS�r qBp�RRC.r.i 77L-/-7/) /f-C2-
NAME Mike McdAI'C[l$'^lN ff truction TEL #
CO CTOR: PO Box 52
NAME West DLiiihRICINI12670 TEL.#
esidential ❑Commercial Cell (508) 280-696` ost of Construction$ /S�
CSL-58633 HIC=169393
Home Improvement Contractor Lic.# Construction Supervisor Lic.#
Workman's Compensation Insurance: (check one)
0 I am the homeowner 0 I am the sole proprietor 0 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: #
Roofmg: #of Squares ( )Remove existing* (max.2 layers) Insulation w/
Old Kings Highway/Historic Dist. (� ac
)Replacing like for like Pool fencing
*The debris will be disposed of at: J e 'I{- J \$C u
Location of Facility
I declare under penalties of perjury that the statements .. contain le 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 revocation of my!ie.". :, . . . f- ution under M.G.L.Ch.268,Section 1.
Applicant's Signature: ,( t Date: ii h./he
Owners Signature(or attachment) ,�j 4 h.t, Date:
Approved By: ... Date: 11 ] •' t Ff
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
lift 312 `-ao2
. ►.'444
A— Permit Authorization
Y1 1Liz'w 30054-
mass saves • Form
Site ID: 3556802 Customer: Derek Fowler
D` ` L FQ,A), ,owner of the property located at:
(Owner's Name,primed)
51 Abel's Road West Yarmouth, MA 02673
(Property Street Address) MMi10)
hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed
below to act on my behalf and obtain a building permit to perform insulation and/or weatherization
::::e:
\\ c
Date: V — 3 a -7 8
FOR OFFICE USE ONLY
We have assigned the following Mass Save Home Energy Services Participating Contractor to the
above referenced project:
Participating Contractor Date
Name: RISE Engineering
Phone: 401-784-3700
Email:
Page l of l For Office Use Only
Rev.102015
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CAie cpo nntooua1 o/o4S;ziacauisea
•
h Office of Consumer Affairs and Business Regulation
10 Park Plaza-Suite 5170
• Boston,'M usetts 02116
Home Improve tractor Registration
I = hfridual
MICHAELMCCARTHY . ' :,YL Registration;a 169393
P.O.BOX52 Expiration: 08J'IFy2019
WEST DENNIS,MA 02670
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Update Address and return card. Mark reason for change.
BCA1 0 20.405/1/
— ---'-_ _..�.f1 Addneee n Rmnawel r1 rmyleymant rl I estCard
652.1 Vov emohaieaS(ciOtukeackedea
AAL
Ohio of Consumer Affairs a Business Regulation
WI
HOME IMPROVEMENT CONTRACTORReglWatlon valid to individual use Otey
TYPE:indMdualbefore the expiration date. Hfoundreturnto:
lt'w'fetretio0 F.>lpl�0ffi Ofioe of Consumer Allaire and Business Regulation
•� 93 0W15/2019 .10 Park Pine-Suite 8170
MICHAEL MCCAHTi � r -y Boston,MA 178
MICHAEL F.M C i1 ?1 }.1
OC , ,../..„' �,2.crla,c. —
B IICHAEL F.
M ' 'tin_nrt U _ r
SOUTH DENNIS,MA 02880 undersecretary Not valid without signature
Tt! Commonwealth of onai ti
husens
Division of Professional Licensure
Michael McCarthy Board of Building Regulations and Standards
McCarthy Construction
Constrgetitld$Upervisor
1 CS-058833
Has euccat}ully Completed the National Fiber^ 'lin`,
Cellulose Training Course �t *fares:04/10/2020 ,
i ._ 23m day of August 2011 MICHAEL J M9CAR'fHYr ';/ '
Po Box 82 � `
WEST 4
de-tart DENNISENNIS MA1.0287� ±��` 4 "1 ..
1 - 'lafartrraeaar neer ,rWc.'ct`1*
-N Commissioner aearraerw NATIONAL Albin 4--
......._.........„.
"^O „NM and what aWosw
• IAN!Is 111Nw,N..
OSHA 001558712 44,0
U.s,Department of Laboroma aakbve- qRf cneihass ; ' i
Occupational Emmy and Health Administration s`F r 2«•earad ` •
w
Michael McCarthy , �..
ArDRe the anhfp[d ,
has su¢esaMycangklede l3M4s ooaganoml Weil'and:bend tl2Roonono fdaRpms71 •ad epee Safely - 1
Tranin2Cdnen 32aahoarser field time •�'::, 7`
"Co •, • Safety&Health !4 ti aesv +gin.— _ ^ i
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1 The Commonwealth of Alassachasetts
. " - ='i DepartmentofIadntial4lt
Fa....i 1 Congress S/roet�S�thsl00
.....__ Boston,MA 02114-2017
Waken'Compensation Insurance bas.
TOME FIZZD TATE TEE PER$lTIIN0 AUTTEORITY.
Mama Informaden Please Print Les@Iv
Name tiw-.1-v_1 litM7 C... ... r,t
p
Address: • 9,G, tsar C.1
City/$tatetZip: we ans..i MSI- OX7'-phone#: ns ->K. -GC cc,
Are yam se a ion1 Mtn,pppr nrbbrat i).pe of project(required):
t,Elanmoon wth 4 mpbyaa(MI one orpandma)f 7. 0New ccnat rcton
T.QIIto ambrmpkbror6emanhband emMrmploYmwading ix=In ✓ n
I. Remodeling
aw'a pe*.pamr'comp.� ate
ranked.] 9. DI Demolition
CI amaSmear=deka all week rasa(No wake&°Dp.hNanc.ueckad]t• 100BulldiDjl Ilion
/.'I w a hamaowoa and will be Ming achaamt.toeondsm dl Wait on any prepay.I win
costa thstaUMetreamnrites have steam'mopeaadaebuamoeaanmole I In Electriodrepe(noradditions
proprietors with no implant 12.0 Plumbing repairs or additions
s.QIansapen common aadlhove liked the seianontotoa listed Mthe seabed ghat 13.�Roofrepairs
Thew adtmoaemhav
om e employees end have mime Nap.ha tr me t
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6.0 We m a.spamlm indite of&mhave eraeladtsirtight oreampdMPaM0t o. 14 00150r
MI,PM.end wehaamemployees.Llowalma'wrap.hweaaaaandl
- ---*Any"pliant tot thecalen elmug also fill out the action below Sowing thee.abm'mapaatapolka b m. •
tRompowoa.who Cade this aide*indicating ewYaedoingAwohaodthenhfnaaddawmmmnmatPASImwdRdvkindkahgsah-------
that additional ft provide Pah w name a'cdie m.pi admawtameramttlmamthtahare
policy manba.
lam an a.plo,er that IsproWdbeg woMen'compensationhemrmaoefermpas,pbyeea. Belowhthe peaty taiga dte
Insurance Company Name: A/4-114-0-1-1 1-4-61 Pay c.-S L.
Fahey;a Selltina.Lie.4: J 1 W C-1.1'75-'7Y Expiration Daus. It I.,f 11i
ob Site Address. City/State/Zip:
IAtfuh the workers'compensated policy declaration page(showing the poEcnumber and expo atbn date). .•
Failure to secure coverage as required under MOL c.15'2,125A Is a criminal violation prmbduble by a fun up to$1,500.00
and/or one year lmpdsomxnt,as well a civil penalties In the form ofa STOP WORK 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 ibr insurance ;
coverage verification. .
Idehereby awe Inter refpojery thetas n](braadda.prorhledderehtrueadcorrect.
Signature: Date: f/riit7
Nine ft: elk).*-C.XL(
OJJ7dal sane on(y< Do not write In this area,to be co npldsdby thy Or town Odd
s
pry or Town: Permit/License#
Issuing Authority(circle one):
1.Boird of Health 2.Building Department 3.City/Town Clerk 4.Electr(ed Inspector S.Plumbing Inspector .
'd.Other
Contact Person: Phone#:
r
.•
...............11111 MCCART9 MCCART9 OP ID.TH
;`�`�o CERTIFICATE OF LIABILITY INSURANCE DATC/01/20YYYY)
o3rotnols _
TH(CCERTIFICATE 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 cerdticate does not confer rights to the certificate holder In lieu of such endorsement(s).
PRODUCER 508.398-6060 2Rir Dennis Office
Bryden&Sullivan Ins Agency PHONE 5084984060FAX 508.394.2267
of Dennis Inc. (A/c,No,Ext): IA/C,No):
485 Route 134,PO Box 1497 WART
So.Dennis,MA 02660
Bryden&Sullivan Insurance INSURER(SI AFFORDING COVERAGE NAIC#
INSURER A;National Liability&Fire Ins
INSURED Michael McCarthy Construction INSURER a;
PO Box 52
West Dennis,MA 02670 INSURER C;
MEURERD;
INSURER C:
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.
INSRI TYPE OF INSURANCE Min yjy0 POLICY NUMBER PoLN:Y EFF POLICY EXP
fMOUCYYYYI JPOLIC EXP LIMITS
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $
CLAIMS-MADE 0OCCUR DAMAGE /Fa occurrence) $
—
MED EXP(My one person) $
—
PERSONAL d ADV INJURY $
_._ GENL AGGREGATE LIMIT APP IES PER: GENERAL AGGREGATE 5 _
R POLICY Lij Loc _ —_ —' '—'--- --- .— PRODUCTS $
---. S --_- —
OTHER'
AUTOMOBILELIABILTY (FeMBIINdent$INGLE LIMIT S
— ANY AUTO BODILYINJURY(Per person) S
AURTEO�S ONLY _ AAUUoTNrIO.pSSyWy�NNEEEOpp BODILYPppINJURY(Per accident) $ _
_ AUTOS ONLY — AOTO$ONLY fPerr acaits/NAGE $ —
— UMBRELLA WB OCCUR EACH OCCURRENCE $ _
EXCESS LIAR CLAIMS-MADE AGGREGATE S
DED RETENTIONS S
A WORKERSEMPLOYERSL COMPENSATION V/N X ST TOTE ERµ
ANY PROPRIETORIPARTNER/EXECIJ IVE V9WC747574 12/15/2017 12/15/2018 E.L.EACH ACCIDENT $ 1,000,000
QFFICE�EMBER EXCLUDED? u NIA 1,000,000
(,MMyyaeenadI MNNNN�) E DISEASE-EA EMPLOYEE 5
DES4tRIPce TIO Ou under
below EL DISEASE-POLICY LIMB $ 1,000,000
•
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached N mon apace la 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
@ ,e.e� Ati ex )6-d-b1-)en
ACORD 25(2016/03) 01988.2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD