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Home My WebLink AboutBld-20-001226 Office Use Only 1 \ /16? t�! O, • Permit# o • 'yr_ . y Amount 3s_-- s '`t. MATTAG LU �' -_,"`°"^tom. :6d"''• 'Permit expires 180 days from -' -=- ::-::..•: :issue date 5Cb--217—W 13-a EXPRESS BUILDING PERMIT APPLICATIO R. E C a ` a.M TOWN OF YARMOUTH ._n f Yarmouth Building Department 1146 Route 28 SEA - i�tC South Yarmouth, MA 02664 e u` i�;r, (508) 398-2231 Ext. 1261 �'--- -` ✓ • - CONSTRUCTION ADDRESS: fc+u...*"-t S ,�.r c� vP✓. IA), t� ASSESSOR'S INFORMATION: Map: Parcel: OWNER: 5 e L`— �Yl`( s:., . S 7E - &33 -04k*-1 NAME Mlle MetEarthyDIEWstrcic ir, l TEL. # CONTRACTOR: PO Box 52 NAME West jammirtt,344 02670 TEL.# Cell (508) 280-6964 sidential ❑CommercialCSL-58633 HIC-16939sof Construction$ 'is---cg"_ Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) ❑ 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: + T ^ v• Location of Facility I declare under penalties of perjury that the statem h mtained 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 m e en "��a" yse f n er M.G.L.Ch.268,Section 1. l f Applicant's Signature: Date: / /3 II ( Owners Signature(or attachment) /lfk(L . Date: Approved By: fc0 ��. / Date: / 3 —fBuildingdesignee) EMAIL SS: Zoning District: Historical District: 0 Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No DocuSign Envelope ID:0F18E9F7-CEA3-44AA-B204-8DFCB936E099 n - B 6 042 CCU 9(,O 9 iof' 2-37 RISE ENGINEERING' OWNER AUTHORIZATION FORM I, STEPHEN G GARIEPY (Owner's Name) owner of the property located at: 52 Crowes Purchase 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. c-DocuSigned by: atteritpl 75Q57114fFGfL Owner's Signature 8/21/2019 111:37 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 • - The Commonwealth of Massachusetts • I! �=e'/ Department of Industrial Accidents 1�7 ilfio w 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 Please Print Lecibly Name.(Business/Orgenization/Individual): MichaenleCarthy Address: PO Box 52 - - City/State/Zip: one 62670. Are you an employer?Check the appropriate box: Type of project(required): I.Q I em a employer with S. employees(full and/or part-time).* 7. New construction 2.01 am a Sole proprietor of partnership and have no employees working for me in 8. Ei 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 0 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.Q Plumbing repairs or additions 5.0 I am.a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 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.[ then Si^�,/�•++, 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 providingworkers'compensation insurance for my employees. Below is the policy andJob site information: Insurance Company Name: NL'�t'or .I Li ;1 i 47 + I"►�'� �,�c Policy#or Self-ins.Lie.#: V 1 k/(,-4`I 3 CPI Expiration Date: 1'a-)1 SI 19 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, enalties of perjury that the information provided above is true and correct Signature: Date: 13-I'fl l F. - Phone#: ( ,t) IC e, 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#: STZ Fo-m,,r7i,61-,?,/,,feebil 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 Expiration: 06/15/2021 WEST DENNIS,MA 02670 Update Address and Return Card. SCA 1 0 20M-05/17 �e Weir nerve¢ e�</, ¢c aSe/4 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: Registration Expiration Office of Consumer Affairs and Business Regulation 1.1 - 06/15/2021 1000 Washington Street -Suite 710 MICHAEL MCCARTY - Boston,MA 02118' ,--''''' rr ! i MICHAEL F.MCCAF THY l 6 RANGLEYLN. �, ,roi'a'lf, sk /(dpt Valid�IvffnOUt si nature SOUTH DENNIS,MA 02660 Undersecretary 4 g COfn " nwreN ash of j. Don0Sachuuusnai ficensfai`e Board Of Building R W i 41115 and Standards Constr ` •isor itas suceistilik COmpistlidtheflationsl F 0i r "' w WEST 'M ,flilsarLllYar 'f`h c4 � ' Mreelar~igebe &A7.1ONAL PHIS* I ovallifasbarmesaasd frOlrtitli III�r�� ' 1 4it oif' . Ulsaay.a. viiiiivaimair OSHA 001558712 a : ..U.S. of Labor occupadonalatIety end Health.Administration , Michael McCarthy , ! +ao grog ►evaa a io+idur o suety aeuut+ea i w eb; -11204:0000.10.-. .- = 3214art liouisardds} " X ICI w wirav„