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E-I 0 -•-• .-: ei a; 'I: vi cil mi 2 co -1 -: •1 ea: -4 4 ei z z Z 0 ra • - - ., • SECTIONS:.CONSTRUCTION SERVICES 51 Construction Supervisor License(CSL) CS-068111 8/17/2020 Michael T McMahon License Number Expiration Date Name of CSL Holder 2 Fuller St List CSL Type(see below) U No.and Street Type . Description Carver MA 02330 U Unrestricted(Buildings up to 35,000 cu.n) R Restricted 1&2 Family Dwelling City/rown,State,ZIP M Masonry 4a RC Roofing Covering WS Window and Siding 781-831-1234 permits.mcmahoninsulation@gmail.com SF Solid Fuel Burning Appliances I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 161816 Michael T McMahon &Son Inc 11/23/2018 IBC Conan Name or HIC Registrant Name FHIC Registration Number Expiration Date 2 Fully St permits.mcmahoninsulation@gmail.com @gmail.Com No.and Street Carver, MA. 02330 781-831-1234 Email address City/Town,State,ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6)) • Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuance of the building permit. Signed Affidavit Attached? Yes 50 No Q • SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT .. I,as Owner of the subject property,hereby authorize Michael T McMahon to act on my behalf;in all matters relative to work authorized by this building permit application. •Brian Long d� �V �y.S , 12/10/2018 Print Owner's Name(Electronic Signature) Date • • . . SECTION 7b OWNER"OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this applicatio is true and accurate to the best of my knowledge and understanding. Michael T MCMahon / , A 12/10/2018 Print Owner's or Authorized Agent' :„e(Electronic Signature) Date • NOTESe 1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L.c.142A.Other important information on the HIC Program can be found at www.mass.gov/ocq Information on the Construction Supervisor License can be found at www.mass.gov/dps 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch) Gross living area(sq.ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" $4391.00 • The Commonwealth of Massachusetts • ___ : Department of Industrial Accidents It �._E Office of Investigations E_= = 3 600 Washington Street raliwa Boston, MA 02111 �� •:._�{` www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): M T. McMahon and Son, Inc. Address: 2 Fuller St. City/State/Zip: Carver, MA 02330 Phone#: 781-831-1234 Are you an employer? Check the appropriate box: Type of project(required): 1.51 I am a employer with 15 4. ❑ 1 am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8, 0 Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp.insurance comp.insurance? required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.]1 c. 152, §1(4), and we have no employees.[No workers' 13.2 Other Weatherization comp.insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy andJob site information. Insurance Company Name: AIM Mutual Policy#or Self-ins. Lic.#: VWC-100-8014109-2013A Expiration Date: �, 12/08/2019_ Job Site Address: On Oridi (-S� /) /PJA d City/State/Zip&Lfil h P 76)14) 1711Q Attach a copy of the workers'compensation policy declaration, a(showing the policy number and Iration date). Failure to secure coverage as required under Section 25A of MOL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. • I do hereby certify under the pains and en fides of perjury t at the information provided above istrue and correct CiBantlit /r Date: 1 s/ial1/I Phone#: 781-831-1234 Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: - Phone#: AccoRD S CERTIFICATE OF LIABILITY INSURANCE DATE MwDaY 11/29/18 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(ies)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 wit rAL NAME: Thompson Insurance (A/C,No.Ezn. 781.335.1890 FAX No): 781.335-9762 and Financial Services e'MAII thorn Infins.eom ADDRESS: j eon P 389 Union Street Weymouth,MA 02190-316 INSURER/SI AFFORDING COVERAGE NAIC 0 INSURER A: Commerce Mapfre INSURED INSURER B: AIM Mutual MT McMahon and Son Inc. INSURER C: 2 Fuller St INSURER D: TOMS National Carver,MA 02330 INSURERE: 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. NOTWTHSTANDING 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. 17R TYPE OF INSURANCE ADDL-r;- POLICY EFF POUCYEXP INSD WVD POLICY NUMBER (MMIDD/YYYY) (MM/DDIYYYY) LIMITS X COMMERCIAL GENERAL UABIUTY EACH OCCURRENCE S 1,000,000 DAMAGE HEN i EL) CLAIMS-MADE a OCCUR PREMISES r(Eaoccunance) $ 50,000 MED EXP(Any one person) $ 5,000 A _ 8008030009088 09/16/18 09116/19 PERSONALSADV INJURY S 1,000,000 GGEEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY❑PE� n LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: S AUTOMOBILE LIABIUTY COMBINED SINGLE LIMIT S 1,000,000 (Ea acddem) ANY AUTO BODILY INJURY(Per parson) S A OWNED AUTOS ONLY AUTOS X SCHEDULED BHJZQP 08/31/18 08/31/19 BODILY INJURY(Per acrldent) $ X HIRED ONLY AUX NONTOS S ONLY NED PROPERTY DAMAGE (Par accident X UMBRELLA LUBOCCUR EACH OCCURRENCE $ 2,000,000 D EXCESSLIAB I CLAIMS-MADE 80313L151AL1 11/24/18 11/24119 AGGREGATE _ $ 2,000,000 DED I RETENTIONS $ WORKERS COMPENSATION PER X OTR" AND EMPLOYERS'LIABIUTY - — ANYPROPRIETOR/PARTNER/EXECUTIVE YI" E.L.EACH ACCIDENT S 500,000 B OFFICERIMEMBER EXCLUDED? �N NIA vwc-100-6014109-2013a 12108117 12/08119 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEES 500,000 U yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ADORE)101,Additional Remarks Schedule,may be attached If more space Is required) • CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Sample Certificate ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE John J.Thompson CLTC ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 10/31/2018 WED 9t45 PAX 4137875469 OR Control Desk 2002/002 • Y' • Fags or Customer Name:BdW1 Long CONTRACT Em.11:blenJmp2®oomca.1.fN eRis �i' Phone:411478-3539 ""`�j Premiss Address:21 Capt.ln Stanley Road,South Yarmouth,MA09664 Dais:Project10:33132955 March 30,2018 ENGINEERING" Efficiency Energized. MBE Cnpinawbp 3 DupontAhnur,eefN 2 South Yenned"MA.02554 Job Description „Yl,l ni In i' 14 St - ` i ''4'11-1411• ;1'hil r, Iii.li II i,i t.WJ ip'j n i,I ,0 >` ATTIC FLAT•4"OPEN R•14 CELLULOSE 1830 SF $2.108.00 $549.01 VENTILATION CHUTES 100 each $349.00 $87.25 AIR SEALING 18 hr $1,280.00 $0.00 BASEMENT SILLS:R19 FO BATT 150 SF $328.50 $82.12 VENT BATH FAN THRU ROOF 2 each $237.50 $58.37 Total: $4,391.00 Program Intently*: •53,613.25 Customer Total: $777.75 WE AGREE HEREBY TO FURNISH SERVICES•COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS.FOR THE SUM OF "'Seven Hundred And Seventy-Seven And 75/100 Dollars $771.75 UPON FINAL INSPECTION AND APPROVAL BY RISE ENGINEERING.CUSTOMER AGREES TO REMIT AMOUNT DUE IN FULL INTEREST OF 1%WILL BE CHARGED MONTHLY ON ANY UNPAID BALANCE AFTER 90 DAYS.SEE REVERSE FOR IMPORTANT INFORMATION ON GUARANTEES,RIGHTS OF RECISION,SCHEDULING,AND CONTRACTOR REGISTRATION. / DO NOV SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES e Q.r+lv17— aP :..•� 4 C .r Slpnat Sign Dale NOTE:THIS CONTRACT MAY BE WITHDRAWN BY US IF NOT ACCEPTANCE OF CONTRACT•THE ABOVE PRICES. EXECUTED WITHIN 30 DAYS SPECIFICATIONS AND CONDITIONS ME SATISFACTORY TO US AND ARE HEREBY ACCEPTED.YOU ARE AUTHORIZED TO DO THE WORK AS SPECIFIED.PAYMENT WILL BE MADE AS OUTLINED ABOVE OCT 3 1 2018 SA/0 DocuSign Envelope ID:1A281728-0B17-4989-AOAD-4177726146F7 1 Permit Authorization mass save Form Site ID: 3367006 Customer: Brian Long Brian Long ,owner of the property located at: (Owner's Name,printed) 21 Captain Stanley Road South Yarmouth, MA 02664 (Property Street Address) (City) hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed below to act on my behalf and obtain a building permit to perform insulation and/or weatherization work on my property. Doeuspn.d�by Owner's Signature: Etritwi., l �: J aenuauu.watase... Date: 12/5/2018 1 8:25 AM EST • FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: /(2//4/� Participating Contractor Da e Name: RISE Engineering Phone: 401-784-3700 Email: Page 1 of 1 For Office Use Only Rev.102015 .2i y reemterAtovre.00 It// Nrto Ontca al Consumer Affairs a Satiam!WSW' n HOME IMPROVEMENT CONTRACTOR TYPE:Conflation ... . ttaal as 1". Conmonwaalth of Maaseehusett$ untie 11129!2020 DNIsi00 of Protafabnal Lkensun MICHAEL T.MCMAHON&8ON,INC. I • Boats of Building Regulation!and Standards Construction Supervisor , MICHAEL T.MCAVWON CS-068111 ' "T' Expires:08/27/2020 2 FULLER 8T ' CARVER,MA 02330 Undersecretary MICHT MCMANON s f ;,; 2FUALAE�ER$T.` t CARVERMA 02898 .�" Pal Commissioner l Ra0Mra0on valid for tadluldwl we only baton the minden data. I found Tatumto•. OM.*of Consumer Affairs and Business Repuiplan Unrestricted Buildings anof onstruction 8 wuP�Nor 1000 Washington Stmt•Suite 710 has than 76,000 e Y grotMp whlM contain Boston,MA 02121 cubic het 41 CUblc meters)of sneloaad / r Not valid without'sign. ur State B h iding Coda: t*Eon of the MasssJRnetts For tnfonnatkn about van The relrecatIon of this Ilan. Cal (S17)72T-0200 or Visit WWWJOassow/dq • DEBRIS DISPOSAL AFFIDAVIT In accordance with the provisions of M.G.L. c.40,s. 54,Building Permit # was issued with the condition that all debris resulting - from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by M.G.L c. 111.s. 150A. • The debris will be disposed of in: • • ABC Disposal • Name of Waste Facility 1245 Shawmut BIvd.New Bedford,MA • Address of Waste Facility • 111.5 Debris: As a condition of bluing a permit far the demolition, mravation, rehabilitation or other alteration of a building or gunner, M.O.L e.40 a 34 requited that the debris malting therefrom Ball be disposed of in a properly licensed solid waste disposal facility u defined by M.G.L.e.III t 150 A.Signature of the permit applicant, date and number of the building permit to be issued shall be indicated on a form provided by the Building Department and attached to the office copy of the building permit retained by the Building Department If the debris will not be disposed of es indicated, • the holder of the permit shall notify the building official,in writing,se to the Ideation where the debris will be disposed. • 780 CMR—6a Edition / Signature of Permit Applicant • • • Ii) i6J/, • Date