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Home My WebLink AboutBld-20-001223 ��, RR Office Use Only Y c O Permit# ISr.r'V C O ii 'R` . H Amount , '-� MATTACM LS[ "°'"°°`°"'°sad Permit expires 180 days from issue date I Gb--2.b?—Od--3 EXPRESS BUILDING PERMIT APPLICATIO TOWN OF YARMOUTH / RECETT --° Yarmouth Building Department ""'�---°• _j" 1146 Route 28 r LSEP - 3wiin South Yarmouth, MA 02664 1 l (508) 398-2231 Ext. 1261 Bu, , E F_.. CONSTRUCTION ADDRESS: ) (j% c •i`c(7 p..).--,)_ Y��_ ASSESSOR'S INFORMATION: Map: Parcel: OWNER: r jl C,_, lc rN 5 St. C.. 1\1 , 3../- YC`'1 NAME Mike Meeiti DStt'uCti,,,:} TEL. # CO TOR: PO Box 52 NAMEl1 WesaenA 02670 TEL.# ivt Cell (508) 280-6964 esidential 0Commercial CSL-58633 HIC-fi553,4Construction$ I G C' 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 V Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: C Location of Facility I declare under penalties of perjury that the statem ei o ' ed 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 e der M.G.L.Ch.268,Section 1. g Applicant's Signature: Date: I h I c Owners Signature(or attachment) s t( <r-`,sL Date: Approved By: . Date: 7 3 --,' Building ci designee) E ADD . Zoning District: Historical District: ❑ Yes 0 No Flood Plain Zone: 0 Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No cog. S311 QjbU/ SF - 3 ( ,xt ,� 21 RISE ENGINEERING" ' _ AUTHORIZATION FORM -3 located at Rc,ad erty (Pry, erty, ressi -:trac`:,:for 3E Engineerinng, to act on my behalf to obtain a building V:3.. : on r. property. This form is only valid with a signed contract. ..Ji 'S Signature -- --tom iSE Eiginee g, a Division of Thielsch Engineering, Inc. font ;venu . South Yarmouth, MA 02664 508-568-1926 zww.RISEengneering.com • _ _ The Commonwealth of Massachusetts t '—� ff/ Department oflndustrialAccidents i:Y10, 1 Congress Street,Suite 100 I. Boston,MA 02114-2017 ~�_L=aa;„ www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. . • TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name{Business/Otganization/Individual): Michael McCarthycC (C, 5i-v- .lTvcn.. roc. Address: P0 Box 52 City/State/Zip: one • Are you an employer?Check the appropriate box: Type of project(required): l.�am a employer with '(. employees(full and/or part time).* 7. 0 New construction 2.0 I am a sole proprietor of partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.]. • 3.0I am a homeowner doing all work myself.[No workers'comp.insurance required.)t 9. Demolition 10 Building addition 4.0i 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.Q Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.1:Roof repairs These sub-contractors have employees and have workers'comp.insurance.! • 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.[t ther 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 tie subcontractors 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: /c3-1',n�( Li cJ ;I i 4-,, 4- ,I'►d-( Fr S Policy#or Self-ins.Lic.#: V 1 k/C3`13 Say Expiration Date: P-)1S 11 rj 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$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify and t e ns 4,, 'enalties of perjury that the information provided above is true and correct Signature: Date: I)-1'f)I F Phone#: (c't) ;AN t/ Official use only. Do not write in this area,to le completed by city or town officiaL • City or Town: Permit/License# Issuing Authority(circle one): • 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: ,.9:4 F'0-/-i-bwo-/-kl("tead.10-/ 4 Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: individual MICHAEL MCCARTHY Registration: 169393 P.O.BOX 52 Expiration: 06/15/2021 WEST DENNIS,MA 02670 Update Address and Return Card. SCA 1 0 20M-05/17 .�Tr Pnrn.wo aureal‘ ✓/SaJJauAte% Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Individual before the expiration date. If found return to: Bevist aeon Expiration Office of Consumer Affairs and Business Regulation 169393— 06/15/2021 1000 Washington Street -Suite 710 MICHAEL MCCART-k Y Boston,MA 0211$" ,�/� - MICHAEL F.MCCARTHY_ i / / 6 RANGLEY LN. ��w 'e.r J J. ��, SOUTH DENNIS,MA 02660 Undersecretary -- Not vaii�Wi out signature ." ...,_ ammo RN(Qa1th of IIA8Ssac ucetts Division ofi -----f-----"re • �McCarthy Board of Building Re Eons'c lans and S#andards: Mq lion iaor , Nes C i the FibW ' CS 5633 • ;: 2°dilyofAl a1t2O11 . �LJ '` PEA BOX62 e'' WEST ' - 'Usk Nilustirisr. fig- •P4..4:4-..4k.• Co mfil't,,$#war OSHA 001558712 440 . . . &ii-6.......a. -..- ( +Mttt of labor '�"' 'a 4 Oration fety end Heath Administration r.. Michael McCarthy f >: a:1Ki11pur QeCtlpefiDtdfseIety eeiif HssIVi Trairon wale fn ag � moe ,.