BLD-19-1840 'to4..y a Office Use Only
CI
3
'.L.'�2'=ter `�p� '1 nPexmiVl G
•'0 ftio � H'C. • !Ammmt r5- De'
N cdx •
Permit expires 180 days from
sLRECEIVED
0 ALI 6issuate
. EXPRESS BUILDING 'PERMIT APPLICATION
TOWN OF YARMOUTH SEp 27 2018
Yarmouth Building Department
1146 Route 28 auitsi T ___
— ---South-Yarmouth;MA 02664 �r,_
(508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS: Y V D(Z ( 0 pat Tho (/' 'N , 914/2
ASSESSOR'S INFORMATION: •
Map:
Parcel:
OWNER: OW: o Z9I# yy� �sV /nsJt1)1)
.072-
_
PRESENT
CONTRACTOR 614/941/M r 32-Ne v4z P& w .9 L- O$ 7 75---573) 9
NAME MAILING ADDRESS TEL#
136estoential 0 Commercial Est.Cost of Construction$ /4 710•• }��
Home Improvement Contractor Lie.# /077 a-3 Construction Supervisor Lie.# D 49 J (J C
Workman's Compensation Insurane : (check one)
❑ I am the homeowner I am the sole proprietor 0 I 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 S nares /012. ( Remove existing* (max.2 layers) Insulation
Old Kings Highway/Ristoric Dist.�/ ( )Replacing like for like Pool fencing
"The debris will be disposed of at )"j z r irp e�- ✓ �i g
11 Location of Facility
I declare under penalties of perjury that the statemen. •ereia contained are true and correct to the best of my Imowledge and belief I understand that any false answer(s)
will be just cause for denial ocation• �.
J ���� f�. G Aas ..n ,�- v., i '.Sectionl.
Applicant's Signature: t&t442 /// _'( Date: 77)-7/I?
Owners Signature(or attachment) # , Date: t// s.0 t,iir /$/—7
Approved By: - C—a/ �e i Date: l b / 7
e l !(or.—i-.ee) EMAIL gr%• SS: f
Zoning District
Historical District 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No
Water Resource Protection District: Within 100 ft.of Wetlands:
0 Yes 0 No 0 Yes 0 No
&sac
E �_ The Commonwealth ofMassadhusetts
' _ =547 Department of Industrial Accidents ,
1 Congress Street,Suite 100
"p • Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print LestibIy
Name (Business/Organization/Individual): 5 /2e0v2/m
Address: ?2- d-0//1-372-- o2L) •
City/State/Zip: U, I/442— 4l Qf 73 Phone#: ? 7 7C 3 39
Are you an employer?Check the appropriate box:
Type of project(required):
I
I. I am a employer with employees(full and/or part-time).*
7. New construction
/00, I am a sole proprietor or partnership and have no employees working for me in
8. Remodeling
capacity.[No workers'comp.insurance required.)
3.Q I am a homeowner doing all work myself 9. ❑Demolition
[No workers'comp.¢uurance required]t
d.❑I am a homeowner and will be hiring contractors to conduct all work on10 Q Building addition
, ensure that all contactors either have workers'compensation insurance or are property.l [��
p11.0 Electrical repairs or additions
proprietors with no employees.
12.D Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contactors listed on the attached sheet
'[hese sub-contractors have employees and have workers'comp. insurance.: 13.Q Roof repairs
6.0 We are a corporation and it officers have exercised their right of exemption per MGL c. 14.0 Other
152,g 1(4),and we have no employees.(No workers'comp.insurance required.]
*Any applicant that checks bac#1 must also ell 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 contactors must submit a new affidavit indicating such.
:Contactors 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 at employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address:
City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152, §25A 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 form of a STOP WORK ORDER and a fine of up to$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certis under �
pat/. d.enalties o .erju , , at the information provided above is true and correct.
Sisnature: P � � / ,,�r Date: 9/4571-2//1F—
Phone
/ 2//1cPhone
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#:
s> • • • Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association, corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the rounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6) also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contact for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicant
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary,supply sub-contractors)name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships (LLP)with no employees other than the
members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised-that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accident. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/ticense applications in any given year, need only submit one affidavit indicating current
policy information(if necessary) and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
r• • Boston, MA 02114-2017
Tel. # 617-7274900 ext. 7406 or 1-877-MASSAFE
Fax# 617-727-7749
Revised 02-23-15 www.mass.gov/dia
M
•
•
Y
€91 f('or monwea/tA 0{Q itaktadenelts * ^
Office of Consumer Affal s&Business Regulation
HOME IMPROVEMENT CONTRACTOR
TYPE:Individual
Registration Exolration
08/04/2020
BRIAN MCCARTHY-' :_
D/B/A MCCARTHY BUILDERS'`
BRIAN MCCARTHY 'i�.,r_��`" U "
32 CARVER RD
W.YARMOUTH,AAA 02673 Undersecretary
Commonweaoh of Massachusetts
®)
Division of Professional Licensure
Board of Building Regulations and Standards
Constructio`SSU eiSor.1 & 2 Family
CSFA-047505 F ires: 09/11/2019
�
i
l 2 y
BRIAN G MCCARTHY '^;� � '4
�
32 CARVER RD `f...4" ,
WEST YARMOUTH MA 0 673 � "1 4731
Commissioner ei