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Home My WebLink AboutBLD-23-005630 o1•Y,,it Office Use Only }` o Permit# E NO 31 os� C E" -1„. Amount 3S ) `g, Permit expires 180 days from issue date i3L,D -013 -6051i 3d EXPRESS BUILDING PERMIT APPLICATI a k. TOWN OF YARMOUTH R E C E l �/ Yarmouth Building Department ------.— 1146 Route 28 South Yarmouth,MA 02664 APR 10 2023 (508)398-2231 Ext. 1261 BUILDING DEPARTMENT CONSTRUCTION ADDRESS: 19 Captian Dore Road -- — —�� ASSESSOR'S INFORMATION: Map: Parcel: OWNER: Forrest Bassett 19 Captian Dore Road 781-831-1234 NAME PRESENT ADDRESS TEL. # CONTRACTOR: Michael T McMahon 2 Fuller Street 781-831-1234 NAME MAILING ADDRESS TEL.# DResidcntial °Commercial Est.Cost of Construction$ 3500.00 Home Improvement Contractor Lie.# 161816 Construction Supervisor Lie.# CS-068111 Workman's Compensation Insurance: (check one) o I am the homeowner D I am the sole proprietor X I have Worker's Compensation Insurance Insurance Company Mane: Aim Mutual Insurance Worker's Comp.Policy# VWC-100-6014109 WORK TO BE PERFORMED Tent 1___I Duration (Fire Retardant Certificate attached?) Wood Stove ❑ Siding: #of Squares Replacement windows:# Replacement doors: # Roofing: #of Squares (0)Remove existing*(max.2 layers) Insulation F- 1 J l Old Kings Highway/Historic Dist. 4J)Replacing like for like Pool fencing El *The debris will be disposed of at: Waste Stream Recycling 16 Copicut Road Assonet Location of Facility I declare under penalties of perjury that the iii- - 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 revocation " -� and for prosecution under M.G.L.Ch.268,Section I. Applicant's Signature r , iik Dom: 4/5/2023 Owners Signature(or attachment) TC H E D Date:: Approved By Date: .4,, s' Building (or !tree) EMAIL ADD S: / Zoning District: Historical District: r Yes "; No Flood Plain Zone: Yes is No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes L'. No li Yes No The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations _law ' Lafayette City Center It! 11 2Avenue de Lafayette, Boston,MA 02111-1750 www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Apolicant Information Please Print Legibly Name (Business/Organization/Individual): MT 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. I am a employer with 15 4. 0 I am a general contractor and I 6 New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling shipand have no employees These sub-contractors have 8. 0 Demolition working for me in any capacity. employees and have workers' insurance.: 9. [ Building addition comp. [No workers' comp.insurance required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3.0 I 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 12.0Roof repairs insurance required.] t c. 152, §1(4),and we have noWeatherization employees. [No workers' 13. other 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 a new 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 and job site information. Insurance Company Name:AIM Mutual Insurance Policy#or Self-ins. Lie. #:VWC-100-601410972013A Expiration Date: 12/8/2023 Job Site Address: 19 Captain Dore Road City/State/zip: Yarmouth, MA. 02664 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for' urance coverage verification. I do hereby certify and ins and penalties of perjury that the information provided above is true and correct Signature: Date: 4/5/2023 Phone#: Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(check one): lDBoard of Health 20 Building Department 31]City/Town Clerk 4.OElectrical Inspector 5tlumbing Inspector 6.❑Other Contact Person: _ Phone#: e rr CERTIFICATE OF LIA BILITY INSURANCE ©A� `A� uDDIYYM THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLES THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSUR REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. ER(S)y AUTHOR/ZED IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the poticy(les)must have ADDITIONAL INSURED If SUBROGATION IS WAIVED,subject to the terms and conditions of thepolicy, provisions or be ment on this certificate does not confer rights to the certificate holder in lieu of suh dor certain�s}, may anrequire endorsement A PRODUCER COMTA4i NAME: Thompson Insurance and PUnanciai Services (ate as r 1: T81-33S1om Z 389.Unlon Street amens: leetinfins.cem Weymouth,MA 02190.316 INSURER($)AFFORDING COVERAGE RAIL S INSURED INSURER A: Commerce Mapfre MT McMahon and Son Inc. INSURER e: AIM Mutual 2 Fuller st. INSURER C: Nautilus Carver,MA 02330 INSURER D: Evanston INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: REVISI THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE�FOR OUCY 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, PAID CLAIMS. EXCLUSIONS AND CONDMONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY 1LTR TYPE OF INSURANCE RODL ILIBR NISD WVD POLICY NUMBER IMINA� UDpVYY ,X ComMEREAL GENERAL LIABILITY �y1f) ' LIMITS I CLAIMS-MADE E OCCUR EACH OCCURRENCE S 1,800,000 PREMISES EB rre,, $ Sti,000 A Y 8008030009088 MED PAP(Artycrra Persef0 $ 6,000- GEN'LAC AGGREGATE LIMIT APPLIES PER: 08/16/22 09/16/23 PERSONAL&ADV INJURY $ 1,000,(I POLICY n ERCaT n LOC GENERAL AGGREGATE' $ ,Z e OTHER PRODUCTS-COMP/OP AGG '$ 2,000,1X10 $ AUTOMOBILE LIABILITY ANY AUTO fE�aMa6 ) LIMITS $010,000, A AUTOS ONLY -SCHEDULED BODILY INJURY(Per pens ) X AUTOS X HIRED -- NON-OWNED Y BHJZQP ©8/31/22 08/3f/23 PROPERTY ROPER JURY(PeraccitJerd) $ AUTOS ONLY X AUTOS ONLY P DAMAGE $ er accident) X UMBRELLA LIAB X OCCUR $ C EXCESSUAB CLAIMS MADE Y AN078737 EACH OCCURRENCE $ 2,000,000 12/19/22 12/19/23 ,AGGREGATE DED I I RETENTION$ S 2,Fd90y 000 WORKERS COMPENSATION _ $ AND EMPLOYERS'I le ar ITV r ANY PROPRIETOR/PARTNERIEXECUTIYE Y!N XC STATUTE F f CERRH Xr B (Mandatory p Ednd}Eft EXCLUDED? N� NIA VWC-100.6814109-2013A 12108/32 12/08/23 E.L.EACH ACCIDENT $ 500,0E yyes.describe NH) E L DISEASE-EA EMPLOYEE'$ J�I7,QBO% DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ 500=000 D Contractors Pollution Liability Condition Limit CPLMOL104901 12/14/22 12/14t23 2,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD lot,Addftional Remarks Schedule,may be attached S mere 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 ACCORDANCE WITH THE POLICY P AUTHORIZED REPRESENTATIVE ACORD 25( 1�03) 988-2 ACORD CORPORATION. All rights reserved: The ACORD name and logo are registered marks of ACORD • THE COMMONWEALTH OF MASSACHUSETTS Office of consumes a Business Regulation HOME _ 4:4 �f • CTOR Oivkkaa of Pruhmiaa)ltae Board of Bu lding- and Stand e MICHAEL T.MCMAH cs i1BS41, °' *treat-n81,Trz022 /�1 2 T 7 (6\\ 0.4RIBMMA MICHAEL T.MCMA °s .•, i� 2 FULLER ST 41`, s` 40(a, ree0+k '1 as a ffiik : CARVER,MA 02330 410 Undei ecrefary Commissioner �t'vorib&.�It_ • .y uar d- °ta which contain • Nord=3Com cubic Net ea6 a mat *of anetosed stone. Registration valid for individual use only before the expiration date. if found return to: Office of Consumer Affairs and Business Regulation 1000 Washington Street -SuIte 710 Boston.MA 02118 lea to Plat*" a caromediion ottheMussidraeBs e Coatis 0°eftl tioasa For intamootoo Below --1/1(41e ..... taB oral*wwwarrasgovidp. Not valid without signature Customer Name:Forrest Bassett CONTRACT Email:vbbgailOyahoo.com Phone:508-394-9033 Premise Address:19 Captain Dore Rd,Yarmouth,MA 02664 RI E. -5.---- Mailing Address:19 Captain Dore Rd,Yarmouth,MA 02664 Project ID:4794454 Date:March 28,2023 ENGINEERING" RISE Engineering 765 Attucks Lane, Hyannis,MA,02601 Job Description AIR SEALING 11 hr $1,037.63 $0.00 WEATHERSTRIP DOOR&ADD SWEEP 3 each $173.76 $0.00 ATTIC DAMMING-R-38 FIBERGLASS 55 SF $133.10 $33.28 ATTIC FLAT-12"OPEN R-42 CELLULOSE 909 SF $1,818.00 $454.49 VENTILATION CHUTES 60 each $209.40 $52.35 INSULATE BULKHEAD DOOR 1 each $68.83 $17.21 Total: $3,440.72 Program Incentive: -$2,883.39 Customer Total: $557.33 WE AGREE HEREBY TO FURNISH SERVICES-COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS.FOR THE SUM OF "'Five Hundred And Fifty-Seven And 33/100 Dollars $557.33 UPON RECEIPT OF YOUR RISE ENGINEERING INVOICE,CUSTOMER AGREES TO REMIT AMOUNT DUE IN FULL.INTEREST OF 1%WILL BE CHARGED MONTHLY ON ANY UNPAID BALANCE AFTER 30 DAYS.SEE REVERSE FOR IMPORTANT INFORMATION ON GUARANTEES,RIGHTS OF RECISION,SCHEDULING,AND CONTRACTOR REGISTRATION% • =NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES - r' V" I il O.9'. _Aix.,oocAtidjiatagazrie RIS'A•�-ntative Customer Signature lemor 4106 1.3 Sign Date NOTE:THIS CONTRACT MAY BE WITHDRAWN BY US IF NOT EXECUTED WITHIN ACCEPTANCE OF CONTRACT-THE ABOVE PRICES,SPECIFICATIONS AND 30 DAYS CONDITIONS ARE SATISFACTORY TO US AND ARE HEREBY ACCEPTED.YOU ARE AUTHORIZED TO DO THE WORK AS SPECIFIED.PAYMENT WILL BE MADE AS OUTLINED ABOVE Page 1 of 1 Permit Authorization mass save Form Site ID: 4773739 Customer: Forrest Bassett i , (i j a SS'e ,owner of the property located at: (Owner's Name,printed) 19 Captain Dore Rd 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. Owner's Signature: AAo-hip47-' Date: 31"" .•ty u a•3 FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: M.T. McMahon and Son, Inc. 2 Fuller St. Carver, MA 02330 tit . o Participating Contractor Date Name: RISE Engineering Phone: 508-568-1926 Email: Page 1 of 1 For Office Use Only 8122f22,4:04 PM Ong-Fwd:Electronic Payment Receipt from nCourt for your OPSI Rene(CS-068111) Your Receipt>> Paid To Name: Massachusetts Division of Professional Licensure-Office of Public Safety and Inspections Address 1: 1000 Washington Street Address 2: Suite 710 City:Boston State:Massachusetts Zip:02118 Payment On Behalf Of First Name: MICHAEL Last Name: MCMAHON Address 1: 2 Fuller St. Address 2: City: Carver - State: MA an: 02330 Phone: (781)831-1234 Description ID Amount •Renewal Fee CS-068111 $100.00 Receipt Date:7/2812022 2:48:59 PM EDT Convenience Fee: invoice Number:e0855422-499d-4100-86c3-ac90b5826c35 Total Amount Paid:$102.35 tip Information Credit!Debit Card Information Name Michael McMahon • Card Type MasterCard Email me mahoninsulation©gmail corn Card Number"'**"*'"•"9677 Street 2 Fuller St. City Carver State!Tertitory MA 02330 Important Information Please verify the information shown above.Your payment has been submitted to the Office of Public Safety and Inspections. • This payment will appear on your statement as"NCOURT*MA OPSIONLii+P-PAY". • For license renewals:your renewal request is now complete.Your renewal wit be processed in the order It was received.If OPSI needs additional documentation,a notice will be sent to your e-mail or mailing address on file.Otherwise,you can expect to receive a new license within 3-5 weeks..You can also check the status of your license at https:/Imadpi.myIlc ense.comAterificationl. • If you have a question regarding your license,please contact the agency at 817-727-3200. • Please note that although the system may show that your payment transaction was successful upon submission,your payment will be considered a pending transaction until proof of available funds in your account has been confirmed. Payments that are denied by EPAY will incur an additional$23 fee to process. • For refund policies,contact the Division of Professional Lkansure at DPL-DL-Accounting@massmail.state.ma.us.Please include your invoice number and license number In your email. httpsJhnaA googb. av 174142380411 17414238r141... 1/1 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 soli disposal facility as defined by M.G.L c. 111.s. 150A. The debris will be disposed of in: Waste Stream Recycling Name of Waste Facility 16 Copicut Rd,Assonet,MA 02702 Address of Waste Facility 111.5 Debris: As a condition of issuing a permit for the demolition, renovation, rehabilitation or other alteration of a building or mixture.M,G.L.c.40 a.54 requires that the debris resulting therefrom shall be disposed of in a properly licensed solid waste disposal facility as defined by M.G.L.c. III s.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 as indicatedv the holder of the permit shall notify the building official,in writing,as to the location where the debris will be disposed. 780 CMR 6th Edition Signature of Perrmit Applicant 4/5/2023 Date