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C 'Permit#
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"`°"b°°it°"p c�`� J -- j,Ur�`/./\/ "Permit expires 180 days from '
issue date
EXPRESS BUILDING PERMIT APPLICATIOF E C E ! V E D
TOWN OF YARMOUTH
Yarmouth Building Department MAY 3 0 2019
1146 Route 28
South Yarmouth, MA 02664 au � P
(508) 398-2231 Ext. 1261 By ` J
CONSTRUCTION ADDRESS: —7 kc.4C C.. U.. 5c..-rr,
ASSESSOR'S INFORMATION:
Map: Parcel:
OWNER: °f-►.c.k.›". ---'d S.h.,L (S�E)^3j `l—le7 L
NAME Mikect5s Construction TEL. #
CONTRACTOR: PO Box 52
NAME NWAIDeVititirg§sMA 02670 TEL.#
esidential ❑Commercial Cell (508) 280-6964 struction$ G"A''CSL-58633 HIe=f4 '
Home Improvement Contractor Lic.# Construction Supervisor Lic.#
Workman's Compensation Insurance: (check one) ,------.---
❑ I am the homeowner ❑ I am the sole proprietor ❑ 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 Squares ( )Remove existing* (max.2 layers) Insulation (.'..-----"
Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing
*The debris will be disposed of at: S4/3- �' (Q
Location of Facility
I declare under penalties of perjury that the s e .ents 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./ ' ense and for prosecution under M.G.L.Ch.268,Section 1. JI
Applicant's Signature: Date: ��13 1 i r
4P
Owners Signature atta:hmen)
Date:
Approved By: � Date: \P ` ? p t,
Building Official(or deli -;,�, EMAIL ADDRESS:
Zoning District:
Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No
Water Resource Protection District: Within 100 ft.of Wetlands:
0 Yes 0 No 0 Yes ❑ No
-tea, 3't-I I °, O
RISES
ENGINEERING C e II - 94 k Sdi/ Q i 4 (L 4 I
C—= - -4I(4 SG! g .- 2 - 2- 1
OWNER AUTHORIZATION FORM
I, FRANCESCO ASARO ,
(Owner's Name)
owner of the property located at:
7 Katama Way
(Property Address)
South Yarmouth, MA 02664
(Property Address)
hereby authorize ,
(Subcontractor)
an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building
permit and to perform work on my property. This form is only valid with a signed contract.
DocuSigned by:
tl,u ii.---)w Qdca--.`-
effSfg9Paturee
4/25/2019 I 8:50 AM EDT
Date
RISE Engineering, a Division of Thielsch Engineering, Inc.
5 Dupont Avenue I South Yarmouth, MA 02664 1508-568-1926
www.RlSEengineering.com
I _
—
P-7-Xe WO4Y142,1,042toetlitA Cli -C/1414:1a-Cheljeirti
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Office of Consumer Affairs and Business Regulation
• 10 Park Plaza-Suite 5170
Boston, ---:-- - usetts 02116
Home!Imre ,ctor Registration
i s ,' , ' '•4
-1.-• ' .-.7. Type: individual
I. • ... ,--zr,- Registration: 169393
MICHAEL MCCARTHY If i &Oration: 06t15/2019
-
-
WEST DENNIS,MA 02670 -
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Update Address and return card. Mark reason for change.
SCA 1 0 20M-05/11
n Aditnyte n Renawall n Employment nLestCgud
&k Weeemoneemai c/bRasaaoiene4
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Office of Consumer Maks&Business Regulation
. - .,, HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only
' w
il
„ TYPE:individual
before the expiration dote. If found return to:
Jo -
..-. !; ', ••
', '•1 EMSE121111
06/15/2019 Office of Consumer Affairs and Business Regulation
1/4,
10 Perk Plea-Suite$170
Boston,MA ,,'11•
CHAEL MC ' 1F-f7,1. LI;
i ci /
ii...c.,.:,:lielf..iciz.- 1,
,.., ,:.•lit ....,,,z-e g j, ,
MICHAEL F.MC.' - /,• 62-cd214— c-----
8 RANGLEY LN. •.19•:k..*. ,
SOUTH DENNIS,MA 02680 Not valid without signature
Undersecretary
•
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."-:'' lir soardpini°113tirldinpingwePaRrtliethtisfatiiMportaissi al:lc:dun:it:It:Wes ards
-
Michael McCarthy
Cons tfUtttbdigiVprvisor
• McCarthy Construction
CS-056633 '...•
' Nes sucessidully Completed the National Ryer. -‹ ,, Ji,..4, , ,Pires:041104020 ,Coadoee Training Course ...
MICHAEL J siroc-1--- ,- r,tr..--: •-•4 Ili"!
' 23/dary of August 2011
PO BOX 62 •-•-_,„ -- ,- —
WEST DENNIS ,, •'--,"` ;:,7'.
., Vain%taskeettems, Hot
Dismbrea.b. NATIONAL POSER C/L I NO vidatrodeaff ealbea . • Commissioner
la-
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,. ....-.: -OSHA 001558712 - ..............,........, - -
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t: CeeisaimaillakfpfeAdocoktercarnmi, : • 7
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U.S.Department of Labor
Occupational Safety and Health Admstration
,,., 2Vett6r4e*teevriti . •
Michael McCarthy .1'..••- ,..'"''.
.=ins'elmaiAvab lhtfigtheeefabfaed Saf
- ' -
et*Coinbistfolt
has iluoceaefully completed a 10-hour Occupational Safety and Health _ • coluse -, . •
raining Colima In ,%., 32 Sem&Oen Mine sada bouts afield ti
COn5tmJSafetv 4 Health '-' : In.
. ,•!,,,,,, 7, cogivotem.e.aes ' -
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...
• The Commonwealth of Massachusetts
Department of Industrial Accidents
•
•
_, I 1 Congress Street,Suite 100
_ �•' 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 McCarthyPlease Print Legibly
Name{Bus;Hess/Organization/Individual): 1V> ichael M CGr.S'I v-..��v�r. �r•-,t:.
Address: PO Box 52
West Jams: 670 -
City/State/Zip: one
•
Are you an employer?Check the appropriate box: Type of project(required):
1.�I am a employer with 45... employees(full arid/or part-time).*
7. CI New construction
2.0 lam a Sale proprietor of partnership and have no employees working for me in 8. ❑Remodeling
any capacity.[No workers'comp.insurance required.). •
3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑Demolition
10❑Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
proprietors with no employees.
12.❑Plumbing repairs or additions
5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 1312 Roof repairs
These sub-contractors have employees and have workers'comp.insurance.#
• 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.[j6ther 1.-✓ )./
152,§1(4),and we have no employees.[No workers'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 anew affidavit indicating such.
tContractors 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 andJob site
Information:
Insurance Company Name: Aic..4.1‘r.,
Policy#or Self-ins.Lic.#: V 1 k/C.?-`I 3 57'/ Expiration Date: i'3-)►C)•
17
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 bya 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 certify and t e ins Ji s enalties of perjury that the information provided above is true and correct
Signature: Date: 11- 'f)I F
Phone#: (St,k) ?. u-(IC ei
Official use only. Do not write in this area,to ke completed by city or town offtciaL
City or Town: Permit/License#
Issuing Authority(circle one): •
1.Board of Health 2.Building Department 3.City/Town Cleric 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#: