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EXPRESS BUILDING PERMIT APPLICA
TOWN OF YARMOUTH � `'- — A "' 1 i
Yarmouth Building Department
1146Route28 SU - 3 '+�q( `
South Yarmouth, MA 02664 - -�'
(508) 398-2231 Ext. 1261 E`"` �'
CONSTRUCTION ADDRESS: /1+ J,S'k--c<on 0r . _ —)
ASSESSOR'S INFORMATION:
Map: Parcel:
OWNER: (U,/' kv\✓N� I->'_SC sr3'• S.►,L ) n` 37ti— i0ce4
NAME MikePli@'an#y9Constructi,._1 TEL. #
CONTRACTOR: PO Box 52
NAME WriBlIfuIS}VIA 02670 TEL.#
Cell (508) 280-6964 )(C- c.'
Residential ❑Commercial CSL-58633 HIelllgc9t3ifYnstruction$
Home Improvement Contractor Lic.# Construction Supervisor Lie.#
Workman's Compensation Insurance: (check one)
0 I am the homeowner 0 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: 4 J �!�C C'
Location of Facility
I declare under penalties of perjury that the st is e' ont ' 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 ce f r ecution under M.G.L.Ch.268,Section 1. Ii
Date: A
Owners Signature(or attachment) 4+1,,E.. .,_ Date:
Approved By: ,� Date:
Building Offic' or ign e) EMAIL SS:
Zoning District:
Historical District: ❑ Yes 0 No Flood Plain Zone: ❑ Yes 0 No
Water Resource Protection District: Within 100 ft.of Wetlands:
0 Yes 0 No 0 Yes 0 No
co& mot /ate
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ENGINEERING' Z2 f 54 `0) < y 2-3 0 Y4—
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: O 1ZATION FORM
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:P., s"ty.- �s
i-&car for 3Er :.igineerif g, to act on my behalf to obtain a building
'. c r c_:=.rty. This form is only valid with a signed contract.
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_ vision .,f Thielsch Engineering, Inc.
o^i Yarmcith, MA 02664 1508-568-1926
;lSEengneering.com
• The Commonwealth of Massachusetts
Department of Industrial Accidents
• EeY11_ a 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 PrintLegibly
Name.(Business/Organization/Individual): Michael McCarthy `Gr. - J v�>. ►-ic.
Address: PO Box 52
------ City/State/Zip: ---------------�e3�� one : •
�-b�-------_._.—_.___—_.--
•
Are you an employer?Check the appropriate box: Type of project(required):
I.Q I am a employer with employees(full and/or part-time).*
7. ❑New construction
2.11 I am d 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. El Demolition
4.0I 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.❑Plumbing repairs or additions
5.❑I am•a general contractor and I have hired the sub-contractors listed on the attached sheet 13.0Roof 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.Other �► a,1 I+..�
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 end 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 isprovidingworkers'compensation insurance for my employees. Below is the policy andJob site
information:
Insurance Company Name: N/r,,•1-t',„",I Li ;�i� •1- 1
V Wit. 1 c
Policy#or Self-ins.Lic.#: 1 k/(.•`I 3 S71. Expiration Date: 1'a-)IC)/
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 punishablabya 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 j 'enalties of perjury that the information provided above is true and correct
Signature: Date: I I'S I I F.
Phone#: (c_t) a(u-G b
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 Cleric 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
„9":4 Focimw,i,toeed.10/ 4
Office of Consumer Affairs and Business Regulation
1000 Washington Street - Suite 710
Boston, Massachusetts 02118
,
Home Improvement Contractor Registration
Type: Individual
Registration: 169393
MICHAEL MCCARTHY ' - . ., - Expiration: 06/15/2021
P.O.BOX 52
WEST DENNIS,MA 02670
Update Address and Return Card.
SCA 1 0 20M-05/17
.9/re Wev-i2.,nevuoserA".6/../Zawaciekie/ht
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
4-09. 3.0 -...,„.- 06/15/2021 1000 Washington Street -Suite 710
MICHAEL MCCAI:MTY: ;'4-,.7-•--,.•: Boston,MA 02118,.... / ..---
MICHAEL F.MCCARTHY - 1 t' /
/ 1”
6 RANGLEY LN. - •' ---: - ..!‘..-s/siott a.1'zeess.4. / ,
.:.,. idmi out signature
SOUTH DENNIS,MA-02660 Undersecretary Not val
, slim of Professional Lk
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