HomeMy WebLinkAboutBLD-19-003356 • 4, Yq OHice Use Only
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`-els)a; **; rCe." -- _- - Permit res 180 days from `"
• issue date
EXPRESS BUILDING PERMIT AP IE--g-TCION—
TOWN OF YARMOUTH UEC 03 201
Yarmouth Building Department __-
,y
1146 Route 28 Dir �RTwet S.c1)
South Yarmouth, MA 02664 By
(508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS: 31 /1 c b« 1 W t $1—
ASSESSOR'S
1ASSESSOR'S INFORMATION: •
Map: / Parcel: hit
OWNER: inti Ca 611
NAME
Mike Mcdaarrt iy`a nstruction TEL. #
CONTRACTOR: PO Tint 57
NAME
West Dennrs, a u2670 TEL#
esidential ❑Commercial Cell (508) 280-69641st Cost of Construction$ /at'
CSL-58633 HTC-169393
Home Improvement Contractor Lic.# Construction Supervisor Lic.#
Worlanan's Compensation Insurance: (check one)
0 I am the homeowner 0 I am the sole proprietor ❑ 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: #
Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation ___ •
Old Kings Highway/Historic Dist. ( )`Replacing like for like Pool fencing
C
'The debris will be disposed of at: S f- c CV.- 6
Location of Facility
I declare under penalties of perjury that the stateme % es/ c. t.'i d ar- rye 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 m *
' I - d , e . on •rider M.G.L.Ch.268,Section 1.
Applicant's Signature: Date: l I>II t
Owners Signatur•(or attach • nt) 'S (Ife Date:
Approved By: ",-.sert / Date:
Bu •mg Official(or des:ra etas(' 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
Sign Envelope ID:4B1DEE13-E/CDA-4A6B-BEBE-0CDE5594405A co.� 334 3\
Fri
RISEc>zt( - c��S4'Q t4 '/ ,�. Lig
ENGINEERING'
— 2-\c1 hOD Stir
•
OWNER AUTHORIZATION FORM
I, Dennis B Cadigan
(Owner's Name)
owner of the property located at:
37 Mcgee Street
(Property Address)
West Yarmouth, MA 02673 ,
(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.
—DocuSlgned by:
' owttrsl tyhature
11/1/2018 I 9:16 AM EDT.
Date
RISE Engineering, a Division of Thlelsch Engineering, Inc.
5 Dupont Avenue I South Yarmouth, MA 026641 508-568-1926
www.RlSEengineering.com
.0.
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1;-.--; Office of Consumer Affairs and Business Regulation
10 Park Plaza- Butte 5170
•
Boston,Ma5thqiusetts 02116
• Home trnprove tractor Registration •
•
..,
Type: Individual• ----
,—
' ...- = 7-- - ..
2.'' Registration
WEST DENNIS,MA 02670 169393 •
• MICHAEL MCCARTHY
P.O.BOX 52 it: =7-4111 r.-72 .:::. , •
-• — - — • •
44-,, •
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Update Atidreas Mai return Gard. Mark reason for.change.'
SCA 1 0 2014-01/1
_ _ _ n Adel ro.at 11 Primeval n Employment II Lesattard
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677,,cennme,,aada ibleasiackaea
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Office of COSIIIIII,Mitre&Business Regulation .
HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only
- rI--. ,, • TYPE:Indivklued before the expiration date. If found return to:
7 i .nteltrai0t1 =MOB Office of Consumer Affairs and Business Regulation
.tir ts42.',..41.169393 06/15=19 10 Park Aloe-Sults 5170
ICHAEL MCCARIer :
-...,, 4ki.m.M.r...47,, Boston,MA ir 116
•;.; ..ti idil
444I,?719.,
MICHAEL F.M .,5.7 /". 612-ceSet--
6 RANGLEYLN. •;:i.,,,I..r., .. i'''
SOUTH DENNIS,MA 02680
Undersecretary Not valid without signature
I itt COMMOnWealth of Massachusetts
et Division of Professional Lkensure
_ ..
Board of Building Regulations and Standards
' '
•
Constrkittiari tttperVisor '
, . Michael McCarthy ,
,
McCarthy Construction
CS-033 588
Has successfully completed the National Fiber• ' ; e ,,, n 14.9:•fres:04/10/2020
) Cellulose training Course ;i
1 " 141. .4
P0m193}1Afox I-62j liatis,,ARCIM'' ' ::
_dei... 23ftl day of Atigust 2011 .
WEST DENNisrmA ovini
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. NIFF : ,
• ". eteosetwat , NATIONAL Place
—....-.......... • Commissioner
4 Net allthatleassobisal '
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OSHA 001558712 .
: 1 - Calm.fearreitrea Cod aroma : i
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U.S.Department ol Labor C:
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Occupational Safely end Health AdmaistratIon ir lialut :4.te Vreette4 • P
Michael McCarthy
en successluflyCoMpleled 110-hour OhhuraltiOnal Safety and Him" ' ,- • • t.' 1, Come
T.ringCounfl
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1 The Commonwealth ofas asachasear
• L..i:'=-==ear Department oflnmaatrld.lcddatts
n ` 1 Corgrteas8haet,Sadbs
_ Ionian,MAf'17I14-2017l00
wwacmmaaon/�a .
Workers'Compensation Insurance Afftdaslh .
TO BIC FILED WITH TIM PERMITTING AUTHORITY.
Mat Intormadon Please Print Led61v
Name b q: /1t ..e.I )1 t ..417 C..ohtalt.. ret c
Address: • QrG. e0 S Z
City/$tate/Zip: wc,?- an-.., Mid- 0)47'Phone#: fl' -x' -Ce"
Are you ampbyeetChad'th bon Tin oflrointO qurea):
4Elimaaepbywwtth °etptoyme(WI ett acpm►dme).• 7. ❑New co sth tion
2❑1massolo proprietor mpartnere*Imam maploeewm*In frmele �, B. ❑Radia{ •
aawasprdq.(Noet'canpsm
Mamas required] 9. DI Detraildm
sat em a baaowew doing all weal;swot[No wdmn'gaup.bras vomited.]t 10❑Building addition
4.01 sora homeowner lad rem be bMtpcoastms m combat ill Work a my popsy.14111
ens that aIt eooaaon etdor bare wean'meWem rlaa L.. as or s sob 11.0 Electrical repair'or eddldon
prop ataa with ao employees. 12.0Plumbing repairs or addition
iJ]tomtpmmlemnmmred1have hind Sms emaamnamedatlmattadmdsteet 13.❑Roofmpaim
nem sobeoaa bast employees ad bare wedeln'sap.tmmaw.t
•
6.0 We waatpondaaand Its officers have ezmolmdMelt right efsnapectpaMt,t 14.00Sf
1i;f1(Qadwebawmemployees.Rbwean'our@.lasso-. Med•1 •
*Sy applicant that chedrbaal mast abo tla alma sum aapamticalroHoy k ommko. • ••
t Bompawmm who submit chi atad4vitediathtg buys doing all work and Pon hbe entakh lesson mot Medi acre affidavit Wats Mak
scootelomm that dna this bat mast attached aaddidaal sham thawing the same tithe thcutamn ad rate whether orsot Masa mire;In
replays. lite wb aotatarr bars employees,they waist provide thole works'caaP poBcyrads
/aa aft employer that 1sproviding workers'compaysdtonbr'unmceJbrtoy employees. Below is the policy andJob die
bOnnedeft
Instance Company Name: /vL-1 Lit-61171 4....9 rel:Cr Vi%.
Policy lioiSelfina.Licit:_J9%-) ctl'7es7V Expiration Data: Itl„It¢{
Job Site Address: CIO/Stan/Zip:
Attach a eoPy of the wetters'compensation policy den page(*swag the patlei under tad expiration date). •
Failure to secure coverage as required under MOL e.I52,§25A is a criminal violation ponhhable by a fee up to$1,500.00
and/or one-year imprisonment,as well as civil penalties in the them ofa STOP WORI:ORDERand a fine of up to$250.00 a • t
day against the violator.A copy of this statement may be thrwarded to the Mice of Investigations of the DIA for instance ;
coverage verification. ,
Ido yaids. ojpej/nrythettkeWheatesnprodttedMore kkweendtortes
�` /
Signature: Duh: 11.417)'suns#: (621t) o-C 7t4( .
Of/dal use only. Do sof write in ebb arra,re be completed by db'or terms official
t
04,or Permit/Meuse#
Towa:
Issuing Authority(circle one):
1.Baird of Health 2.Building Department 3.Ctty/fown Clerk 4.Electrical Inspector S.Plumbing Inspector
.6.Other
Contact Person: Phone#:
•
I.
J
t....--••••1 MCCART9 OP ID:TI-
,AOR o CERTIFICATE OF LIABILITY INSURANCE °A /0112018 )
•
o3ro11zo1B
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 polley(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 22 AcT Dennis Office
Bryden 8 Sullivan Ins Agency PNONE 5083984060 FAR 608394-2267
of Dennis Inc. (AIC,No,Est): (AIC,No):
485 Route 134,PO Box 1497 $D"tnkss:
So.Dennis,MA 02660
Bryden S Sullivan Insurance INSURER(31 AFFORDING COVERAGE NAIC B
INSURERA:National Liability&Fire Ins
INSURED Michael McCarthy Construction INSURER B:
PO Box 52
West Dennis,MA 02670 INSURER C:
INSURER 0:
INSURER!:
INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE USTED 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.
ITR TYPE OF INSURANCE ADDL SUER POLICY EFF POUCY EXP
IVCD WYD POUCY NUMBER IMMIDD/YYYYI IMMIDDNYYYI UNITS
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE i
CLAIMS-MADE ❑OCCUR DAMAGE
TO
EeENT RENTED
$
—
MED EXP(Any one person) $ _
—
PERSONAL a ADV INJURY $
GERI.AGGREGATE LpMpRAPPLIES PER GENERAL AGGREGATE i _
POLICY u JECT U LOC PRODUCTS-COMP/OP AGG $ _
OTHER $
AUTOMOBILE UABIUTY /Es
COMBINE
AUTOMOBILE LIMIT $
ANY AUTO BODILY INJURY(Per person) i
_ OWNED
ONLY _ SCHEDULED
NEEEODD PBPpOpDILY INJURYTy (Per accident) i
AUTOS ONLY — AUToS ONLY (Perr eccWWent)AMAGE $
S
—
UMBRELLA UAB — OCCUR EACH OCCURRENCE $
EXCESS UAB CLAIMS-MADE AGGREGATE $
DED RETENTIONS $
A WORKERS
X SATUTE !TI-
MID
ANY PROPRIETORVARTNER/EXECUTIVEY V9WC747674 12/15/2017 12/15/2018 E L.EACH ACCIDENT $ 1,000,000
KFCERM�MBER EXCLUDED? N/A 1,000,000
MAaWry n E DISEASE-FA EMPLOYEE $
R yea,describe under
DESCRIPTION OF OPERATIONS below , E L DISEASE-POI ICY LIMIT $ 1,000,000
DESCRIPTION OF OPERATIONS/LOCATIONS(VEHICLES (ACORD 101,AddISaW Rmnares Schedule,may be attached IImore 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 POUCY PROVISIONS.
Cape Light Compact
Box 427
Barnstable,MA 02630 AUTNORQED REPRESENTATIVE
ACORD 25(2016/03) ®1988.2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD