HomeMy WebLinkAboutBLD-19-003962 Ce se y
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EXPRESS BUILDING-PERMIT APPLICATION f
TOWN OF YARMOUTH ----g V E ca
Yarmouth Building Department
1146 Route 28 JAN 03 2010
South Yarmouth,MA 02664 su ar
lel `�1
(508) 398-2231 Ext. 1261 I
CONSTRUCTION ADDRESS: 1 93. 1 L4 tb
ASSESSOR'S INFORMATION: •
'r/1 Map: Parcel:
OWNER: ^'"I crvnr-. 5.^ t._ tak) 737 —W ?Z
-- ' - -- - - NAME • _ _ Mike McGaathtt'struction TEL. #
CONTRACTOR: PO Box 52 _ _-
NAME West DarinisoMAs02670 TEL.#
Cell (508) 280-6964
esidenfial ❑CommerciisL-58633 HIC-16 393t of Construction$ )LCA
Home Improvement Contractor Lic.# Construction Supervisor Lic.# •
Workman's Compensation Insurance: (check one)
0 I am the homeowner 0 I am the sole proprietor 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 t...."--.--
Old Kings Highway/Historic t.D s ( )Replacing like for like Pool fencing
"The debris will be disposed of at JILJ es C J
1 Location of Facility
7
I declare under penalties of perjury that the stat- u h ei ontained 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 o se r prosecution under M.G.L.Ch.268,Section 1. ��
Applicant's Signature: Date:_ (y
Owners Signature(or attachment) 4ADDRESS:
Date:
Approved By: , Date: / 3 19
Building ci r designee
Zoning District:
Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No
Water Resource Protection District: Within 100 R of Wetlands: "
0 Yes 0 No 0 Yes' 0 No •
•
wA►4 Sob 3l 4(,52_N�• -rr Permit Authorization
mass save Form ei:I nsoss mu an
sawrgs M,W,Vn enemy errxignry
Site ID: 3617122 Customer: Patrick Fannon
< C crest. r b ,owner of the property located at:
(Owner's Name,printed)
81 Taft Road West Yarmouth, MA 02673
(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.
J
Owner's Signature: \ R �0 �
Date: I 2-I ( aO\ \ 1/46
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 1 of 1 For Office Use Only
Rev.102015 _ �
•
n,
Office of Consumer Affairs and Business Regulation
10 Park Plaza-Suite 5170
•
Boston,: . usetts 02116
Home Improve +�L tractor Registration
1 _;--. Individual
MICHAEL MCCARTHY z _ Registration: 169393
P.O.BOX 52 h i iµ Expiration: 06/15/2019
WEST DENNIS,MA 02670 %t
1— -
l •7 `�
•
`�� see
Update Address and return card. Mark reason for change.
SCA 1 O 201.1-05/11
—' —_— —..._,11 AAerrree r1 Renewal 11 Fmploymad n Lost Card
C in s Wommonamaleg oy6 alaackme n
A. _. . _ _. _.. ._
•, — WM roumv/dtaln k Beatnaa R T" bn
HOME MPROVEMENT CONTRACTOR Registration valid for individual use only
v• stTYPE:IndMdual before the expiration date. If found return to:
(1 f s ExnlmtIor Office of Consumer Affairs and Business Regulation
08/16/2019 10 Palk Placa-Siete 6770
r d,,
ICHAELMCCJI{}Ttf r • •31- Boston,IAA rte
MICHAEL F.M ;
8 RANGLEY Lit ,u,, [� —p,Y ._
SOUTH DENNIS,MA meth
Undersecretary
Not valid without signature
• ._1 ; - r Commonwealth of Massachusetts
I^ f Otr(slon of Professional Licensure
Michael McCarthy eo+ro of Building Regmations and standards
&IccrtltyConstruction • ConstrytOt►dtltit
Pervisor
• Has succassfullY Completed dm Neuse!Fiber^ CS-056633
*Dirac 04/10/2020 ,
Cellulose Training course r � t 1'
23'E day of August 2011 MICHAEL J Ht cArt I.
Po BOX 62 ,
� FI
�a - WEST t)ENNIS MA,02870 - +,`'} #
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" �,� ;r:t.`�
'F• Ons101aTER. NTION`L plaER w//'� Commissioner
aks elu.erae0aad
Lorniaree,.n,...
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OSHA 001558712 ?
$i
" cess_akt./cnw •
U.S.Deawts.nt of tabor . E.P QRt tetld¢R;aa a
Occupational Safety and Health Administration F• yy -‘
Michael McCarthy 4 i
has aur»ssfuyconpleted a 10-hour Ocapronal Soley and Health u.ceamaea -
•� � owmnmw sareFy
Carle lOn
Trae.q Cane h' 32 ReeaerOoRT,..M S toi,a,j eldt1ine I . 7`
Selety&Health .. . :.. t .
). , y. a7R,4"-. —
9/9/07 v `,.-4 M 42.L.�wit
lam.z.eit4.
, !Dote! . .
14 The Consn onweaRh of Massachusetts
1^= =a D oflndasMahle ts
V
n_ 1 CosgnasStee4Sadte100
• Boston,MI 021142017
Workers'Compensation Insurance Affidavit adPhmbers.
TOPE HUD WITH THE PSRMITIING AUTHORITY.
Sat Information Please Print Legibly
Name nn G• /'I.�.,�1 11 Y..�I 7, C..,y► ,.. ,c ;
?
Address: ' • e. C2-
/
City/$tate/Zip: wc,r?- an.•y M/I- oM7`-phone#: SzI ->fa ,CTc c
An yea a ea,arrt adctee TWO glued(required):
t,dihnaemployer with rempruPillalsoyem(lbIsed/arpeatIme}• 7. ❑New conatnm6on
21:1lemaRob pmpdaorofprank mid lave aemploye.working Pormela I. al Remodeling •
- .myashy.[No wades'an.immhma ] J
1.01 me aMotaowaehdoingAmow+at(Diawadaw'amp.haulmregMdlr 9. Demolidan
Building
•4.OImeow
ehooetaedwillta6Mwobo
Wring 100 tln
tame that ill woeerooeither lave war ae'wmpeondoetatr nFraaaole IinElectrical repairs oradditioos
'ptepie'with m employees. 12.0Plumbing repairs or additions
S.Qlemapencil Gorman end Ilave liked the abegattrosets Iliad onthe nehedsheet I3.0ltoofrepairs
Tone e�•mmmaton myna end haw acne temp.lma
ma t •
•
6.0 We as aaatpanmtadItscentaveatadnddakdgkofao4aapclata 14.00fher
I72,uta and wehave w employee.No acne an.lamamsregdmd,)
*Any applicimttladie atomstmustohoCUmtSnudabdswshowingtbmrwataa'wmpmataapolbkhan= ••
T t ammeoawto submit Mb Oda*lndisahgamyere doing all work and thea its ands te etude eon submit amw Alava indicating suck
tCoamtaaa add Iamh box tort ached an Salami shetMowingaa tame oftte a bcadrr and maand=a me ton nth%have
employees. NS lave employee,they mit provide their wades'an.paaq wan.
t emmremplgerthatIsprovidingwerkas'oaapaveBmetanmrncelbrwgemplojes. Mew it the policy maga da
Wiwitgatlets
Insurance Company Name: /v-41«•.i 1-4-6:17117 c-....9 "Fyn CC ,.
Policy##orselfiaa.Lk.ft:_J9 CPI,'5"-P1 Expiration Data 13 Its I t A
lob Site Address. City/State/Zip:
Attach a espy niche worlara'compensnloe policy declaration page(shelving the Oki camber and expiration date) ••
Failure to secure coverage as required lmderMOL c.152,(25A is a criminal violatloaptmhhable by atine up to 21,500.00 •
and/or me-year Imprisonment,as well es civil penalties in the tam of a STOP WORKORDER end a fine of up to 2250.00 a
day against the violator.A copy of this statement nay be forwarded to the Office of Investigation of the DIA for bnamae
coverage verificative. •,
f e
Idehereby weander +,�,�ofperjwythanks ttdSrnsalloNp ortdedabove traraesadconed
Signature: %` '%— Dale: /I>I'7 /
OQ4del use only. De not write in this area,to be eontp/etedbyeh"ertexw W eld
City or Town: Permtt/Ltmau#
Issuing Authority(circle one):
1.Bard of Health 2.Building Department 3.City/Town Clerk 4.Electrlal Inspector S.Plumbing Inspector
6.Other
Contact Penson: Phone#:
•
r
�'1• MCCART9 OP ID.Til
ACORO CERTIFICATE OF LIABILITY INSURANCE DATE IMMIDDIYYYY)
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 508-398-6060 ortteCT Dennis Office
Bryden&Sullivan ins Agency PHONE 508.398-6060 rAX 508494-2267
of Dennis Inc. (AIC,Na En): (NC,No):
485 Route 134,PO Box 1497D'$ ss.
So.Dennis,MA 02660
Bryden&Sullivan Insurance INSURERS)AFFORDING COVERAGE NAIC F -
INSURER A:National Liability&Fire Ins
INSURED Michael McCarthy Construction INSURER s:
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 PND CLAIMS.
INSR TYPE OFINSURANCE ADDL SUER POLICY EFF POLICY EXP
ITRwho WYD POLICY NUMBER IMMIDIWYYYI IMMIDONYYYI UNITS
—
COMMERCIAL GENERAL LABILITY EACH OCCURRENCE $
CLAMS-MADE IDOCCUR PREMISES(ERENTED
occurrence) $
—
MED EXP(MY one Peron) $
—
PERSONAL S ADV MJLRtY $ _
GENL AGGREGATE LIMIT APPLIES PER: GE_NEB L AGGREGATE S
POLICY u;Es, u LOC PRODUCTS-COMP/OP AGO $
OTHER: $
AUTOMOBILECOMBINED SINGLE LIMIT
LIABILITY $
(Fa s IdeMl
— ANY AUTO BODILY INJURY(Per person) I
_ OWNED
AUTOS AUTOS BODILY INJURY(Pe acddenl) S
AUlTfOSONLY _ AOSOp POzntAMAGE
S
S
—
UMBRELLA LAB — OCCUR EACH OCCURRENCE $
EXCESS UAB CLAIMS-MADE AGGREGATE S
DED RETENTIONS $
A AND EMRPLOYEMPENSATION RS'LIABILRY X STATUTE FORµ
V9WC747574 12/16/2017
12/15/2018
1,000,000ANY PROPRIIETORIPAEXECUMiu NIA ELEACH ACCIDENT $
".dS1NMN EXCLUDED?
E.LDISEASE-EAEMPLOYEE $ 1,000,000
If yes describe larder 1,000,000
DESCRIPTION OF OPERATIONS below F.I. DISFASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached Near 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 POLICY PROVISIONS.
Cape Light Compact
Box 427 AUTHORIZED REPRESENTATIVE
Barnstable,MA 02630t n
I lA
ACORD 25(2016103) ®1988.2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD