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�; Permit#
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EXPRESS BUILDING PERMIT APPLICAT D E I V E D
TOWN OF YARMOUTH
Yarmouth Building Department SEP , 4 2019
1146 Route 28 .
South Yarmouth, MA 02664 B UILDING DEPARTMENT
(508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS: ) 7 A
, N. .Jc J1-•
ASSESSOR'S INFORMATION:
Map: Parcel:
OWNER: S)- '-•l -v/ Nc(-) 5.+^, 345--(Ry7—/I
NAME I iV lJ 1W� Q ethy COnstruciic,_A TEL. #
CONTRACTOR: PO Box 52
NAME MWWSOCIAttifelS,MA 02670 TEL.#
Cell (508) 280-6964
sidential 0 Commercial CSL-58633 l 1 11 tion$ ) 6Gv ---
Home Improvement Contractor Lic.# Construction Supervisor Lic.#
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
Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing
*The debris will be disposed of at: 54 -C-7C Cc
Location of Facility
I declare under penalties of perjury that the sta m he ein ntained 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 e or prosecution under M.G.L.Ch.268,Section 1. Vy
Applicant's Signa -. i Date: ii f
Owners Signa re(or attach I nt) c.L. Date: '/
Approved By: `'� Date: 7�Y '/�
Building Official EMAIL ADDRESS:
Zoning District:
Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No
Water Resource Protection District: Within 100 ft.of Wetlands:
0 Yes 0 No 0 Yes 0 No
L(4-1 I I ( I
pig ?ock '
RISE a r —,75(( < (2-= I
ENGINEERING"
OWNER AUTHORIZATION FORM
I, Stanley Neu
(Owner's Name)
owner of the property located at:
179 Springer Lane
(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.
Owner's Signature
-2_
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
Department ofIndustrialAccidents
•
-'eY to 1 Congress Street,Suite 100
•, rf • Boston,MA 02114-2017
•
�11.1� www.mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
•
TO BE FILED WITH THE PERMITTING AUTHORITY.
AivlicantInformation Please Print Legibly
•
Name{Business/Organization/Individual): Michael McCarthy
Address: PC) Box 52
— -- City/State/Zip: ------- West ltll-� b�none —
Are you an employer?Check the appropriate box: Type of project(kegnired):
1.j I am a employer with employees(full and/or part-time).* •J. ❑New construction
2.0 lam a sole proprietor or 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
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.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.❑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 a 14.[ then
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 ail 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:
Insurance Company Name: h...+ 'on,I Li ci- ;I i 4/ + �i f'C r
Policy#or Self-ins.Lic.#: V q k/C-4-`I 3 531. Expiration Date: 1'a-)►5-1 I7j
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.bps 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 e nsey 'enalties of perfury that the information provided above is true and correct
Signature: Date: 11-)'(I i I-
' • Phone#: (S�t) .)-to-CSC('
Official use only. Do not write in this area,to he 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#:
a4ehOfficeOffice 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
...0)7,3 WernmeraemaA'',.ye,/k.a.s.teze...4-4.ielZ
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
169393 _,_- 06/15/2021 1000 Washington Street -Suite 710
MICHAEL MCCAlitii-R:7--,-. .-:,, Boston,MA 021164 / /. /. • -----
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MICHAEL F.MCCARTH{: • • 0: / //
6 RANGLEY LN. , ---' -,v „e.,,,,,,Hfea 1 alio•4
..,- Not valicLeifttiout signature
SOUTH DENNIS,MA 02660 Undersecretary i,
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• . .. . .
; . ,er; 11 Division of Profession' I Le usetts
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Board f guild! —a -itenStite
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Coltdose%Ming Course
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