Loading...
HomeMy WebLinkAboutBLD-19-003357 ,F'YA 0 ce Use Only R� z: o �19-07>3 OitiONI H Amount `--�a - Permit expires 180 days from �jSS•-"' • issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YAROUTH rt E p ; M Yarmouth Building Department 1146 Route 28 DEC 03 • South Yarmouth, MA 02664 ZO18 (508) 398-2231 Ext. 1261 ;1!356:61 ;,'"•,_,1 ,0 IV CONSTRUCTION ADDRESS: 3V �1,,/+.,..- . \-- ASSESSOR'S INFORMATION: • Map: -/ / Parcel: X38 OWNER: '(e), f hcc-•.. 5...&t. 77C(-ZI)--)1'7/ NAME Mike Mcea IyDconstruction TEL 0 CONTRACTOR: PO Rot 57 NAME West fithiliiiOW 02670 TEL.N ❑Irsidential 0 Commercial Cell (508) 280-6904 Cost of Construction$ /6 Cc.-- CSL-58633 — CSL-58633 I-IIC-169393 Home Improvement Contractor Lie.# Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor Oil 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 Se RS- debris will be disposed of at I Cx(Cc, Location of Facility I declare under penalties of perjury that the statements her• 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 revocation of ce osec G.L.Ch.268,Section 1. ff-- Applicant's Signature: a h r Date: a- k I r- Owners Signature • , , 1 / air Date: Trio Approved By: N? rigor Date: Building Officiai�QJr'.,�7 EMAIL ADDRESS: ��" 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 .4`� to. Permit Authorization TN -2, 2 In-( mass save Form Swings through energy~wry C I L./aft)`Q u ,L--1 d Site ID: 3452764 Customer: Robert Ericson I, ,owner of the property located at: (Owner's Name,printed) 385 Highbank Road South Yarmouth, MA 02664 (Property Street Address) (City) 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 work on my property. Owner's Signature: `A /\, • Date: T- 2-/ -'- /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: For Office Use Only Rev.102015 ...- vi r vgce Wpoan?nn0,1i0ea a/c��/4Ai d sac resel • = Office of Consumer Affairs and Business Regulation ' 10 Park Plaza- Suite 5170 Boston,_M usetts 02116 • Home improve tractor Registration 1 Type: Individual MICHAEL MCCARTHY -z; f Regtstratlorrg 169393 P.O,SOX 52 ^t 4 Expiration: 06/15/2019 WEST DENNIS,MA 02670t. ', r:. , ==70..-- .-.....-"'—' Tr y 4y • • Update Address and return card. Mark reason for charge. 3CA1 A 20M-05/11 ' _______ _... .r'1 Arelreeu I'1 Renewal ii Fmplcymsnt ry l oat Card -- els%nnnoiumsat (cyt asaadfraeaa _., Office of mAH neuwatre&Susanna Regulation Registrationy; HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only b' TYPE:IndMduel before the expiration date, if found return to: it ksnr trp6 Elleimftan Office of Consumer Affairs and Business Regulation 06/15/2019 10 Park Plaza•Sults 5170 ICHAEL MCCA�r ' 3 `• Boston,MA sr 116 a '1i 11iii,• MICHAEL F.MC ,;: ,y,_,.- SOUTH DENNIS,MA 02660 Undersecretary Not valid without signature u ,®1 Comrnonweakh of Massachusetts Div/siotrof Pr oressionatLkensure Michael McCarthy award o►euilding Regwattons area standards Constr:tettOrf.`fx rvisor I McCarthy Construction F'S, • Has suoarteully Completed the National Fiber" CS 058633 " Y, Fdt area;04/10/2020 , Cellulose Training Course r p 23Id day otAugust 2011 • MICHAEL J PACCAR . e4 : PO BOX 62 sY WEST DENNIS M '`r ,J "t • A 02876 +. 7 CtaM.par MnaSr6aarr FastN %;����13� ` • Ohara a/la s NATIONAL MINIM l NarlrerlmMaa a/lesaaad '+-•+ Commissloner / 1r01miniaN.ti, - OSHA 001558712 . �°° as; -.g:.at.e=„reSte ' "15 , PSIS US.Deperent of labor r Occupational Safety and Health Mm, ,stratlon . i •�. • ., M Michael McCarthy "`� 1 treepte4` . flea mJ eSShayddngfetada 10-In,Ceapatbns Safey and Heath Aew( g„ad� Safely , rS TmMYla Couaa fn - 3a Ream ofl]am Ca jflo : a 7lmsand ahouaor}leldilma `Corls@u Ion Salely 6 Heahh x w ...a+aua.A,..,A.o . R lOetel i'I4`'.r nr. J, . lee— The Commonwealth ofMassaehuset s it_ _,,+i S ar�entoflr�lalAccidents n_ 1 Contrieas&reekSalle 100 -I" LTSestets,MA 02114-2017 wwstlnastgoidla • Workers'Compensation Insurance Affidavit TO BE FILED WITH THE PERMITTING AUTHORITY. .4e ,LEhhrmatlen Please Print Leath Maine p q: f 1w.L 111 t—tir 6-44.4.4.A,.. e Address: ' Q'G. ger S 1 City/Ftste/Zip: 1,.101- an..., Mie- 01(74-phone#: 5z4 -340 'Char M.you no Medban Type e(pr*Jed(required): t.(c+m a'Mon witheopbyaa 01d1 ondlarpi*der), 7. ❑Nevi caosfrxtion 2❑ranapbpapdetoratpemarhipand have seemployees mita fix me ha B. n)i n apathy.No 'amp.Inseam required.) 9. 0 Demolition 1.❑leon iki mwoedokaanwekmadt(14o�'�R ' •1t 10❑Building nddidon •4.❑t ma brown we/will behkbgeantrntaemeoadowdvmkeemypmpey. Iwfid emote see ail ea-haeeaaeither have wmtem'compensation Surcceaamode 11.❑Electricalrepairs oradditions "prowl:m.0 m eaplymea. 12.0Plumbhig repairs or additions 6a I mama!contractor and Dave hired the rbemtranmn Used on the ensued not 13.QRoofrepairs Themb e emtrmmn employees emphryand have workers' im'®m t . • 6.0 Ws fie seaman end W ofceshaveeawdstdeheIrdaf totaumptionplata c. 14.0Otber IS;stat and wehave m replant plo weirs'mane.him=tegdnd3 •Aa applicant St ebedabon#I neat at fill oath soden beim showing thdrworkers'ecemniationpolicy Marra. •• t Bompowaaa who submit this dank they are doing all week and then hire omit contractors oast submit anew affidavit indicating ouch tnntammnSat cheek ildskwmoststandaneddtebnaldratdewing6enadaofthemi•cmesaraadnaewhetherornotdoaStieshaw employees. Bb anbemwmon haw moployee,they mud provide their vwdrma'conch policy nit. Ilain an nuplu,rr dud it providing worken'commotion insurance firu Jr employees Mow ttdheporky andJobsite bpfbnnottcn. A./....h.......4 .. luaunnceCompany Name: /V�b1...-4 1-1<b.bh.il, c...9 htie 1+-1. Policy#ot'Seif-ins.Lir.#_Ji id c-ri-psi L/ IskpimtioaDate: I3 les I t ft Job Site Address: Cil p: Attach a copy of the workers't empeoaatlel policy declaration page(showing the pe& Bamber and expiration date). Failure to secure coverage as required ender MOL c.152,625th is a criminal violation punishable by a fine up to$1,500.00 • and/or mo-year R as well as civil penalties in the firm of a STOP WORK ORDER end a fine of up to$250.00 a day against the violator.A copy of this statement may be tbcwarded to the Office of Investigations of the DIA for insurance : coverage verification. I do hereby cent 'ander, 'U— gfpes jwy thetthe I*rowdonprovided dbow Sr traradcorrect $ianat re: %� � Date: L./.417 ribce#: art) o-C Mt( Official en we. Do not write in this arae,m be complied by thy or town offie al tPermif/lfann# Ciq'orTown: Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.CitytTown Clerk 4.Electrical Inspector S.Plumbing Inspector '6.Other Contact Petton: Phone#: r • MCCART9 OP 113.114 ;`�`c„1 CERTIFICATE OF LIABILITY INSURANCE Cr DAA(MMDD!YYYT • 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 508-3984060 Far Dennis Office Bryden 8 Sullivan Ins Agency PHONE 508-398.6060FAI 508-394-2267 ofDennis Inc. (AIC,No,Ert): I(AIC,NO So5 Route 134Denni ,MA 02660x 1497 isala ksE, Bryden&Sullivaninsurance INSURER(S)AFFORDING COVERAGE NAIC INSURER AI National Liability&Fire Ins INSURED Michael McCarthy Construction INSURER s I PO Box 62 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. USSR TYPE OF INSURANCE INep VNO POLICY NUMBER POLICY EFF POLICY EXP lMOLIC YEFF IPOLIC YEXP LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE 0 OCCUR PRA AGE TO RENTEDISPS(Fa ance) S MED EXP(My one person) PERSONALS ADV INJURY S GEML AGGREGA LIMIT APPLIES PER: GENERAL AGGREGATE $ R POLICY AGGREGATE n LOC PRODUCTS.COMP/OP AGG S OTHER' f AUTOMOBILE LIABILITY (Fa aaBc ae tSINGLE LIMIT — ANY AUTO BODILY INJURY(Per person/ S _ SCHEDULEDOWNED AUTOS OS BODILY INJURY(Per accident)AAUOS ONLY _ AUO PRrcdyyt) AGE S 1 - S _ UMBRELLA LIAR _ OCCUR EACH OCCURRENCE EXCESS UAB CLAIMS-MADE AGGREGATE S DED RETENTION S A WORKERS COMPENSATION X PER D - AND EMPLOYERS'LIABIUTY STATUTE ERTH V9WC747574 12/15/2017 12/15/2018 EL EACH ACCIDENT S ANY PROPREIETORI RIEXECUTNE1 000,000 tory In EXCLUDED? N/A If .describe under EL DISEASE-EA EMPLOYEES 1,000,000 DESCRIPTION OF OPERATIONS below EL DISEASE-POI ICY LIMIT 5 1,000,000 • DESCRIPTION OF OPERATIONS A LOCATIONS I VEHICLES(ACORD 101,Addltonal Remarks Schedule,may be attached If men span 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, NOTCE WILL BE DELIVERED IN Cape Light Compact ACCORDANCE WITH THE POLICY PROVISIONS. Box 427 Barnstable,MA 02630 AUTHORIZED REPRESENTATIVE 114d 3P-z ACORD 25(2016/03) • ©1888.2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD MMCCARTHY CONSTRUCTION CO. MMC Date: f 1/ mjmccarthyconst@gnail. cornBuilding Commissioner Building Department PO Box 52 —co`"�"1 West Dennis,Ma �'L0' t 06 33�r 02670 To whom it may concern, This affidavit is to certify that all work completed for Permit Location: 'S 14,4 h fj p N I G, 2 .5 y✓�2�►v�,�l Has been inspected by a certified Building Performance Institute(BPI)inspector. All work performed meets or exceed Federal and State requirements. Sincerely yo rs,; • Michael McCarthy RECEIVED SEP _ 4 2019 BUILDING DEPARTMENT By-- -