HomeMy WebLinkAboutBld-19-006708 ��,�, Office Use Only a
\\ 0 4 - Permit#
0� - $ E/ }� `ct _ -7 Amount 35
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*Ansu"00 ECd Permit expires 180 days from -'
„1 issue date
EXPRESS BUILDING PERMIT APPLI
TOWN OF YARMOUTH SAY 30 2019
Yarmouth Building Department
1146 Route 28 -—` a
South Yarmouth, MA 02664 B
2C (508) 398-f2f23 1 Ext. 1261
CONSTRUCTION ADDRESS: ✓V A- 1 De-+--• ' 9 • V'1 ,
ASSESSOR'S INFORMATION:
Map: Parcel:
OWNER: K4/4 •^N 131..1 -., S.ri"- Li —171/4/—u..1 -'1
NAME Mike McCarthy Como-action TEL. #
CONTRACTOR: P NAMEWest D D Box 52
{44E9;670 TEL.#
Cell (508) 280-6964
esidential ❑CommZ''
��L-58633 HIC-1693�3=ost of Construction$ ) S
Home Improvement Contractor Lic.# Construction Supervisor Lic.#
Workman's Compensation Insurance: (check one)
0 I am the homeowner ❑ 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: #
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: SA- 7LC ci
Location of Facility
I declare under penalties of perjury that the statemen h ein co t ' d 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 of my li f p ecction under M.G.L.Ch.268,Section 1.
Applicant's Signature: Date: c41 l i
Owners Signa ,re(or a ,<chme t) ,c.),�"--- Date:
Approved By: 4.7 Date: i ~ I'l5
Buiidin i ibee) EMAIL ADDRESS:
Zoning District:
Historical District: ❑ Yes ❑ No Flood Plain Zone: 0 Yes ❑ No
Water Resource Protection District: Within 100 ft.of Wetlands:
0 Yes 0 No 0 Yes ❑ No
— RISE cs,. -f - L )2_ c61 a -2
ENGINEERING
OWNER AUTHORIZATION FORM
1, Kristin Blackman
(Owner's Name)
owner of the property located at:
38 Alden Road
(Property Address)
West Yarmouth, MA 02673
(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.
1
np )14 AI\lazi-
Owne ignature
2-1
.Date
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RISE Engineering,a Division of Thielsch Engineering, Inc.
5 Dupont Avenue I South Yarmouth, MA 02664 1508-568-1926
www.RlSEengineering.com
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Office of Consumer Affairs and Business Regulation
10 Park Plaza-Suite 5170
Boston,: ... . uSeUs 021 16
Home Improvem1Iractor Registration
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....
_ ...........______
- __ ....,. Type: Individual
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=...--.......-7 , •z -, Registration: mos
MICHAEL MCCARTHY .-; ....._.:4 , . •:-...• Expiration: 06t15/2019
P.O.BOX 52 P"' ----.7-_.L....-•-74,==.-, 1..1
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WEST DENNIS,MA 02670
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Update Addressand return card. Mark reason for change.
SCA I 0 2014-05/11
n AAdmits ri Pertatarof n Employment n Le:bate:mil
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-- Office of Consumer/Maks&Business Regulation
HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only
TYPE Individual before the expiration date. If found return to:
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- ‘ , ,,.,•,, expkiggg
06/15/2019 Office of Consumer Affairs and Business Regulation
10 Park Plaza-Butte S170
ICHAEL MC Boston,MA .e 11• -•
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MICHAEL F. ,
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8 RANGLEY LN. •.1(..,i.-.; ,:
SOUTH DENNIS,MA 02660 Not valid without signature
Undersecretary
....,..., wealth of Massachu tts
' .f.--7------------------------------"-- """1"1"-Igr Div ofn Professional Licensesure
_ _ ... _
ifBoardCociftwmfilitifildin a Regulations and Standards
f* •
• Michael McCarthy ,
Cons,t,r40414..1416"'oufx,rvisor
McCarthy Construction
CS-058633
' Hee eueesestufiy Completed the National Fiber• .;-; ''' -2: 4,Pires:00012020 ,Calkdorre Training Course -- - , . —
.., 1- .*...• 4 MICHAEL J mcc , „_ _:-._ --•
, ted day ot August 2011 .
PO BOX S2 '"-=., :ti,: -2:
: AdiOr '
WEST DENNis*
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lawsw.taii. NATIONAL PUIMR
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OSHA 001558712 ,,,,,,
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001.00111.ibilktP/.rrAtla COW CstinfiabiNa fil. 34:.- ...
US.Depirfmant of Labor .,
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Ocarlianional Safety arid Health Administration ''1 os” -. -
3rdes‘et Nreedite4
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,.Michael McCarthy I.' ' II
ch.* CDIrt Platinkexabfred
has svccessmycorrokted o 10-hour occupational.Safety and Hann Allabst&COnbuttion Safety . `. ,4
'..:. 32 ROM°Mass ThrelecluSeend 8 bouts afield time —r "k,
Tabling Cause in
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r...._/ , ,._,nsIn . *deity fi.Health 2 •
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•• - The Commonwealth ofMassachusetts
►�— �—_=G't Department oflndustrialAccidents
•
• ie1111-s 1 Congress Street,Suite 100
_f Boston,MA 02114-2017
• Y�2r—„ www.mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
• TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information L Please Print Legibly
Name{Business/Organization/Individual): Michael leCarglly
Address: PO Box 52
City/State/Zip: -- -- -- West Dennis vtKO267U
one
Are you an employer?Check the appropriate box: Type of project(required):
LE I am a employer with '(. employees(full and/or part time).
7. 0 New construction
2.0 lam a sole proprietor or partnership and have no employees working for me in 8. D Remodeling
any capacity.[No workers'comp.insurance required.). .
3.01 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. Demolition
4.01 am a homeowner and will be hiring contractors to conduct all work on my property. I will
10 0 Building addition
• • ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
proprietors with no employees. 12.0 Plumbing repairs or additions
5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.11Roof 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 a. 14.�ther i r'}I 1 l+
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.
: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 fob site
Information: 1
Insurance Company Name: N�'�t'c.n� Li EL;I i 47 +
•
Policy#or Self-ins.Lic.#: y C '1 57`/ Expiration Date: i'a-)10 17j
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 r' 'patties of perjury that the information provided above is true and correct.
Signature: Date: ' f)t F
Phone#: i jiik) i- j-G IC y
Official use only. Do not write in this area,to lie 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 Cleric 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#: