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Home My WebLink AboutBLD-19-003958 O... OPe ICC rmmY Sc y / ` # 4 2. . O ., . : DocuSign Envelope ID:BD1F3240-7051449F-9140-82B208E779BBto( 1 e L y Permit Authorization 47-(144111 mass save Form C. � Savings through thew eminency '22.G,�—D •-• $ Site ID: 3460657 Customer David Cohen I, ,owner of the property located at: (Owner's Name,printed) 23 Gaslight Drive Yarmouth Port, MA 02675 (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. o« binesiaoee s {]A461' CAUL Owner's Signature: ava»mFronFans 10/29/2018 I 4:45 PM EDT Date: 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 C 2e Wogn nOincoeaAia4z a - mac Zulel:r ` Office of Consumer Affairs and Business Regulation • 10 Park Plaza-Suite 5170 Boston,M usetts 02116 Home Improverii tractor Registration ---i. • Individual MICHAEL MCCARTHY — = `," Registration: 1%393 P.O.BOX 52 "I — Expiration: 06/15/2019WEST DENNIS,MA 02670 �' , �1 • . - \A‘,.4:- / ,bSCP . Update Address:and return mrd. Mark reason for eliangA SCA 1 O 201e-0SI11 ----- py ___. 1'1 Addnl�w n Ronwavwl I.1 Fmpinvmwnf C�I eat Card &A. ester lose Baia a CA:soadeasA3 Oma M mumarAffalre t Business Raeuhtbn w HOME IMPROVEMENT CONTRACTOR Rsglstratlon valid for IndIvIduel use only s TYPE:tndMdual before the expiration date. If found return to: r_ - ,: €d Elmlmtian - — -- - - Mae of Consumer Affairs and Business Regulation - - _ O&15/2019 10 Park Plaza•Sults 5170 S• as' ICHAEL MCCAR7r t.._:,41..- /Alf 1 Boston,MA ^11� "1 MICHAEL F.MC ', , ,1 ,p.�.� SOUTH DENNIS,MA n undersecretary Not valid without signature Bea I Consti "41 C°IniMnsveeRh of Massachusetts Divlo ' Michael McCarthy • Boob or eatmn-0ftdingProfessional Regulations Lieandenstandsure ards Construction � t `rutt rf�ufVisor fi Has succestly Completed the National Fiber^ CS-058633 Cellulose Training Course ft `W `, *Aires:04/10/2020 , • 23"0 day ofAupwt2011 POBox62 f�ccAR 1 ��s I WEST DENNIS MA 028701 r • �`' } •,wl+4wor rear MIFF- r sc.1.I`rt� , ' • • nlYarbMeaaa - NATIONAL FIauR �. a 1 NMr ed minasel6wad •..ne+�rw.«.... Commissioner t///m'. I+On111„Oarwu•.. 4 > OSHA 001558712 it, rnl,aa, � .,:,:_ . US.Department of Lite: <�! "..•ruu,laa r OccuMtbnat Safety end Health AEminhltratbn b l_yyel e Michael McCarthy g. . .�,,� t , "Wr�'"I'�.q tT1a c006laee hat successfully completed a tones om+naiblxl Safety and HealthCTewm11{,yagd�A Course• a0ombtsfoe II It TrtlN„e couasn sa Soma ofGmTN, eeeaaafdeld Uma i 7 g • Safety a Health ." 9/9/07 `;:,.M A:Y.`».'W •1 -e•...f.,__ • 1:St 3h1mpR.fOratlCC011y0nwalth Ofat0fM tnef s 44CCfriGb1` y !l 1/401/4 — ' 1 dra�SSrha l00 n= • _ ' Boa MA 021144017 /Workers'Compensation Insurance etTPlombe s. TO BE FILED WITHTHE PERMITTING AUTHORrrY. ifiggthsetIntormation -, .Print Lealbly Manse ttc.L._I ilY..-4y C..,yhe+ti.. ri,e Address: ' 9.o. 6/�ar//�� c..1City/$tate/Zip: 'Jø� ane.., 114- 01t7•-p1pne#: -tt -pc. -[T(4 Are you mngMyantCheek herr Tyr efpaled(require4 t,.d/iemaemployer wIh employee(thlI intlior pme).• 7. QNew eart :dial . 2.QIananhpepAecorerpamaddptad harem employees waides!Ormehir, S. Remodeling ' W'a - -- ptly.INo waters'comp.hma=repkda P. g Demolition ... .. 3.0 Ianahmrmwowdotes ell we*swede(No wadsn'maw.Immo=rgdmd.]t 10 tling addition -- - 4.Qlamahmra ormreadwNMh4fesm traecoretocondamdlWokonmyproperty.IavN MOM tetdieaatrameaeither have waken'compensation insea aeraresok II.QRlec4ica(reran Oradditions ••proprietors with so employees. 12.0Plombingrepairs or additions I.0I am a general eamaomr and I have hired to subcontractors ltd mem inched that 13.Qltcof repaint Thew mbmoaamaa have emplanes sod ham workers'comp.Inmanoe t . • 6.13 Weere aaapamatendksomenhave mendedtheir ddaofeaemptanpmIda o. 14.0Ofber 132.PM and wehave memployees.(Nowdana'ampiomaneetrgdrdl *Any eppthmathe Meeks boa al east atm ea as the sante bakwahowhrg tb*wortaa•aapmtm policy hlcomatbo. •• t ttompowmawho submit this tenant taakdns they ere doing all waked then like odd&Si omit mhmka new affidavit Indicates etch t mtekomra Pod check this boa mot attached as ad&tarol Meat showing the on of the mbsaon eters sad tote wkther a not those amides have e mploy's, geambmmamon have employees,they milt provide their workers'amp patt rest lam an employer that Is providing workers'co npendon dnaroncelbr a4 employees. Behar Is the pollee al site bitbrotstlen. AL L'•••4 AL•••4 LP<Ssttit a.9 Rt rt.$. Policy tV OISCIDS.Mit: J 1 W G.1•1 151 4.f Expiration Date: I3 l,c Jif teStateair Job Site Addresr «Attach a copy the workers'compensation policy declaration page(showing the a poReyy number and expirationdate). • Paktum to secure coverage as required imderMOL c.152,§25A is a criminal violationptmhhable by a fine up to 81,500.00 and/or one-year imprisommm;as well as civil penalties is the&DI ofa STOP WORL ORDER and a fine of op to$250.00 a day against the violator.A copy of this statement may be tbrwarded to the Office of(nvestigadons of the DIA fir insurance coverage verification. . •: I do hereby ears ender- q/ped ny Menke Wittmetleoprostied above is bee ext coned planes: east)?to-C.Fact • • Official use only. Do not eerie be this axe,to be completed h'dbmtown eel City or Town: Perrdt/Lieense d . Issuing Authority(circle one): 1.Boird of Health 2.Banding Department 3.CitylTown Clerk 4.Electrical Inspector S.Plumbing Inspector '6.Other Contact Pluton: Phone d: e r MCCART9 OP ID:Ta ,ket.ant Cr CERTIFICATE OF LIABILITY INSURANCE DATE(MM,Da7YYY) • 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(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 508-398-6060 gizr CT Dennis Office _ Bryden&Sullivan Ins Agency PHONE 508-398-6060 I"I 508-394-2267 of Dennis Inc. (Arc,No,Etl): We.sea 485 Route 134,PO Box 1497 Wai&ss, So.Dennis,MA 02660 Bryden&Sullivan Insurance INSURER(S)AFFORDING COVERAGE NA/C0 INSURER A:National Liability&Fire Ins INSURED Michael McCarthy Construction INSURER s: PO Box 52 West Dennis,MA 02670 INSURER C: INSURER 0: • INSURER l: ' 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. ---- jI TR TYPE OF INSURANCE I�p SUBR . POLICY NUMBER POLICYMIDDEFF POLICY EXP IMOLID(YEFF I POUCY EXP LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 5 CLAIMS-MADE 0 OCCUR DAMAGE TO RENTED PRPMIS_ES IEa eci=—1 S — — MED EXP(My one person) $ — PERSONAL&ADV INJURY $ GENt AGGRE ATE LIMIT AP IES PER: GENERAL AGGREGATE ; H POLICY • Li!inLi LOC PRODUCTS-COMP/OP AGO ; OTHER S AUTOMOBILE LIABILITY (Fe eoclekmtl E LIMIT S - — ANY AUTO BODILY INJURY(Per person) ; OSCHEDULED BODILY INJURY(Per seddent) ; AUTOSWNEONLY _ SCCHHEDD P� AUTOS ONLY — MOM (Per ezR Y R"GE ; S _ UMBRELLA UAB — OCCUR EACH OCCURRENCE _ EXCESS UM CLAIMS-MADE AGGREGATE $ DED RETENTIONS $ A ANDEMPLOYERS' X STATUTE FR"l- ANYPROPRIETORIDARTNERIEXECUTNE Y/ V9WC747574 12/15/2017 12/15/2018 1,000,000 fALFFICE mI gay EXCLUDED? y N/A E.L.EACH ACCIDENT & "'andslory In NM) E.L.DISEASE•EA EMPLOYEE f 1,000,000 Ilya de enbeunder 1,000,000 DESCRIPTION OF OPERATIONS Below E.L DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Seeadub,may be attached If more apace 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 02630 4 nAu. o I ll ACORD 25(2016/03) • m 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD