Loading...
HomeMy WebLinkAboutBLD-19-003969 ice se y I yy01*Valk r .Permitil±eXPfrnOdaYSfr4 issue date EXPRESS BUILDING PERMIT APPLICATION----- --------i TOWN OF YARMOUTH 011.9 Yarmouth Building Department JAN3 t.. 1146 Route 28 BD i ` r South Yarmouth,MA 02664 By 1 W (508) 3398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 2 ) �rc hct 9Se {21k1,i/c't ASSESSOR'S INFORMATION: • Map: Parcel: • OWNER: SColt v;2J ., S.nl 7d I 'Q a--3 qn NAME Mike Meefisa Lonstruction TEL. # CONTRACTOR: PO Box 52 NAME West MiRWINEV132670 TEL.# esidential ❑Commercial Cell (5118) 280-696At Cost of Construction$ )52C4 ---.— CSL-58633 HIC-169393 Home Improvement Contractor Lic.# Construction Supervisor Lic.# 1 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: # V Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic D st.11 ( )Replacing like for like Pool fencing *The debris will be disposed of at JI J e�C` Location of Facility I declare under penalties of perjury,that th em herein 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 repocati a and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: ( /�_t1 Date: ,ilii iOwners Signature(or attachment) . /�A-EJ.�- Date: Approved By: � Date: / 3 % Q Building Offc' ar igne EMAIL DRESS: 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 •^75I 25-k 3487 DocuSIgn Envelope ID:A87FA528-DD12-47B5-A6D2-FB25F950483C Permit Authorization mass saw Form c_eil — 576 SCI 13 � tbtf s Site ID: 3567488 Customer: Scott Muizulis 1, Scott Muizulis ,owner of the property located at: (Owner's Name,printed) 21 Trowbridge Path 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. �Docusianed by: Owner's Signature: I Scoff Autolt lis D19CC1822191345A... Date: 12/17/2018 1 12:09 AM EST 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 oft For Office Use Only Rev.102015 t Cr 04ts� CliC/GQ'cfdQ°CiZtLJet s „- 1:171E, ' Office of Consumer Affairs and Business Regulation • 10 Park Plaza-Suite 5170 • Boston, usetts 02116 • Home improver�r filactor Registration ) Type:. MICHAEL MCCARTHY i_ f `< Registration; 169393 P.O.BOX 52 �, I Expiration: OW1W2019 WEST DENNIS,MA 02870 , L_. Update Address six!Mum card. Mark reasonfor.change. SCA1 A 20M•05&11 —�'"' _ .__..fl.£ddre s r•1 Ranswsl rl Fmployrnont r1 Loat Card (i.�axsHosux4(1Oiawadaae4A -- Office of ConeumKAOaxn a Business Regulation • HOME IMPROVEMENT CONTRACTOR a' - • TYPE:IndMdual before the Registration wild for Individual use only ' expirationumerdate. R found return to: 1' Wlsben°n 19mlmtiga Office of Consumer Affairs and Business Regulation j 181393 08/152019 .10 Park Plexe•Suits 6'170 ICHAEL MCCAEt7•Ti' �"' �i Boston,MA ••116 y , i.. -Y MICHAEL F MCCgAT . /I: 8 RANGLEV LN. •afr,I.: SOUTH DENNIS,MA 02880 Undersecretary Not valid without signature - " ®� Commonwealth of Massachusetts Division of Professional Licensure Michael McCarthy Board or Bultding Regulations and standards MCCaLissyCot Combustion Constr�lCtltSrtit11p4rvisor 1 CS-058633 ' Has s ly completed the National Fiber^ *Dims:04/10/2020 , c.Undoee Training Course .. � 23nlday ofAugust 2011 • PO d 62 RCC .1414 5 i .'.. WEST DENNIS MA 02670tt ,`1' ,.� tasafrearaear• N ti;I*`;,_ioS� ma Maar - NNAtIONF 1. plain _ e �i . ', NorseedaWralassaesd . w-"+-^i Commissioner ,t/• R`4 ��.— - - - OSHA 001558712 s v t..r.re.srrr..c,,es>M,c . U.S.Depvnm 4of Labor +< Occupational Safely and Heald)Administration ,y lc ,. Vay Michael McCarthy `° "� `ea` ` s`° i°y�TM° ammeed , has wocessktyoonpieled•10-hour OcapaliorW Salary end Heath 32 aeon orCLsoun emu Course Sere h Traheeg Caron •rinya„d Bheoaoraald Wee 4 '. ion$aletya Heelm '. . � ' 9/07 ( til rw .:: ,m. .:.1 (Date) 'r'r�•`..a..w w•.Tw 14 The Commonwealth of Massachusetts '>_ Departments ofltaiattrialtleedentts n_ 1 Congress 3tn c Salle 100 - ` Boston,MA01114-=017 1 wwataeanam✓_ta • . Workers'Compensation Insurance Affidavit here. TO BE FILED WITH THE P1126Wr ING AUTHOR:Y. ddpantlnfenna8en Please Print LeelbI Name /'I.cl.,_( 11 tM7 C...sheaJi . .e Address: • 9.C1. ger S 2. City/tate/4: 'x-it,?' 1l,....) 114- ox7'-phn e#: sat -?at "city Are pee rseorrrl Cadbox: TIM ofProlsst(req : Lilian melon whh '' .apbrrrr(MIandktpsalms)! 7. QNew cooaMucdon _.. 2.Qlwas mberapkoraeemn6bmdbars eorm ayru'addoe fame lo - 6.DI❑Eelcodeiag - • ren wpm*(No wastes'amp.Sorra t+einas•1 et 9. alDemolid® 7.Qtamahmrawne au weds War No nub&oxen,Snugf• IOQBuilding addition 4.QIamakatarmasad Mil bebMnacontactorsmcondmta0notteamyrya*Iwle nwsS sit.-S' --eiterhavewaken'meQea s.im maaramsole lI.QEladrialrepairsoradditions ••propitiate with mrmptoyma. 12.071umbingrepairs oradditiona 50 I am a gaud cantata sod nava bad tbs atsootnaten fisted on the MSS sheet. 13.❑Eoortepeirs Th . • en aobcammbn Inn employees ban amp.p.Imasom t 6.0 We aamtpaadmandittot[knbanemnlmddednljhtahrm@dmparl n.e. 14.0lkher - , m 152,11(Q,and we bays no employees(No vadat era.lane tatp ' d.l °Ani.wsanttottacksboaelaaat.hoMIaatheaead%belowalowimeta_masa ca %ply tabooed= •• ta..r aawtoaahmhahhamdattfodlatiagtheymedansa0wothadthenbiteamidecometemumlmhtorsatHdavitheli sot treat=that that thbboamat teethed uaddend%eatthawing theteterids e aomaasadsate anthem as those SS baie smpioyas LYdia aabconbacbxs Mn eaploy.as,they must provide stair wake? laman°ploy°drat isprowlerworkers'compensationhmwancejbra yempbyees. Below Is the policy&Slobshe -ft Insurance Company Name: AM .-i 14'-5,Par 4.-.9 ►�-rvre.TZI. Policy#oiSelf-ioa.L(o.#: J 1‘,.1 c'7'I.7r7'l Expiration Date: IA II I I ft lob Site Address; dip: Attach a copy of the welters'compensation policy declaration page(*owing the pafiej■ambounci expiration date) Failure to secure coverage as required ander MOL c.152,17.5A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the(brmofa STOP WORK ORDERsadafine of up to$250.00 a , day against the violator.A copy of this statement maybe fbtwarded to the Office oflnvestigitiom of the DIA fix Insurance coverage verification. . Ids hereby c t&ander olpedwyth tthebp'brmaUowprorNadtborelrartsndeonret / She Date: /Jr I, phi#: elk)?in-C,7t,ti Oolalal mat only. Do not write In Ns area,to be completed by aiy or town eclat City or Town: PenuMicense# Issuing Authority(circle one): 1.Bead of Health 2.Building Department 3.CIty/lown Clerk 4.Electrical Inspector S.Plumbing Inspector . •I Other Contact Petson: Phone If: L • r MCCART9 OP ID.TI{ `,`�`� CERTIFICATE OF LIABILITY INSURANCE Cr DATE 03/01/2018 Q os/otnola 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 ADT Dennis Office Bryden&Sullivan Ins Agency PHONE 508398-6060 FAX 508394-2267 Of Dennis Inc. (AIC,No,Ext): I(AIC,Ne): 485 Routs 134 PO Box 1497 obnkss So.Dennis,MA 02660 Bryden&Sullivan insurance INSURER(S)AFFORDING COvERAGE NAM N INSURER A:National Liability&Fire Ins INSURED Michael McCarthy Construction INSURER B: PO Box 62 West Dennis,MA 02870 INSURER C: INSURER D: INSURER!: 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 POUCY 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. INSR TYPE OFINSUMNCE ADDL SUBR POUCY EFF POUCY EXP LTR 'NW WVn POLICY NUMBER IMM/DD!YYYY1 IMM/DDNYYYI UMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1 CLAIMS-MADE IM OCCUR DAMAGE TO RENTED PREMISES!Fa ocartenrel 1 MED EXP(Mv one penon) $ PERSONALS ADV INJURY $ GENL AGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE 1 _ -I POLICY IJ j I I LOC PRODUCTS-COMP/OP AGO I OTHER: S AUTOMOBILE LIABILITY (EaM�d.ntI SINGLE LIMIT ANY AUTO BODILY INJURY(Per tenon) $ _ OWNED SCHEDULED AUTOS UTTOONLY AUTOS BODILY INJURY(Per accIdenq AUpOSONLY — AOOl PniyDDGE ; $ — S — _ UMBRELLA UAB _ OCCUR EACH OCCURRENCE S EXCESS LAB CLAIMS-MADE AGGREGATE S DED RETENTIONS $ A WORKERS EMPLOYERS'ERS UABIUTYSY/ X STATUTE FRS ANY PROPRIETORRARTNERIEXECUTIVE V9WC747574 12/15/2017 12115/201$ !LEACH ACCIDENT S 1,000,000 (Mandatory In N )EXCLUDED? Y N/A 1,000,000 ( es,decry !!l1111�) E.L DISEASE-EA EMPLOYEE S II s,describe under 1,000,000 DESCRIPTION OF OPERATIONS Delco/ EL DISEASE-POI ICY IMIT E • DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remade Schedule,may be attached limon space I.rpulrsd) 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 Cape Light Compact ACCORDANCE WITH THE POLICY PROVISIONS. Box 427 AUTHORIZED REPRESENTATIVE Barnstable,MA 02630 1 e n I lJ� ACORD 25(2016/03) - ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD MMCCARTHY CONSTRUCTION CO. MMC Date:` 71/ mjmccarthyconst@gnail. cornBuilding Commissioner Building Department PO Box 52 T°"i"� oc West Dennis,Ma �L D' 1 0 o3i foci 02670 To whom it may concern, This affidavit is to certify that all work completed for Permit Location: 21 120wB,2_,11 5 c ptr i L y4E1-10Jth Has been inspected by a certified Building Performance Institute(BPI)inspector. All work performed meets or exceed Federal and State requirements. Sincerely yo rs,; P Michael McCarthy RECEIVED SEP 4 2019 BUILDING DEPARTMENT By