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Home My WebLink AboutBld-20-001221 .,..Y-- Office Use Only x O ` .4-- �; Permit# t1 C (O/� - ' 1l• .. .'] Amount ` Mutt n CS �•' -�,1`°'""'l°'9 i 1. s Permit expires 180 days from -* . ' issue date 8C13--7!)--0Cl)-( 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 / /. /. • ----- , ,- - ---- , _,.--- --„-- .- // ; , if • , / -! 2 MICHAEL F.MCCARTH{: • • 0: / // 6 RANGLEY LN. , ---' -,v „e.,,,,,,Hfea 1 alio•4 ..,- Not valicLeifttiout signature SOUTH DENNIS,MA 02660 Undersecretary i, . ,- • . .. . . ; . ,er; 11 Division of Profession' I Le usetts . aloha.,wealthy Board f guild! —a -itenStite % ° "11.9.6 MO.,.,_ana and Standards • C84:086:03x61°11::: :Htvi::,a:se:7N r ilikemitiby Cometructlan ,.., .._ '' Kas succioNtU4y Ctimpistil the National noir' - ) .45. ,...,,.,,•-•;• , forret:off,,,y,I::5. Coltdose%Ming Course ite day of Ague*2011 . , . micHAEL J ,, •, -," Ati: x.C° -,°•7.-, ":".", . 14:, • — '. - • WEST Mies *- :ma • -144.-43....• .' - 'MMIe.11Mtesilliber• . Obeelerelikise 4 NATIONAL PION* . Nof t•Mtwsker ealitiessd • .81/110,.11S..0.1.1.•••••P...... CCInirnhateller ‘c,i4. 4---- , . ,5„„„„,........... - . 2 . _ . . . OSHA 0015-58712 • - ..... .. .._ , ,........ , :;- . .-sty end Health Administration 04t Michael McCarthy -. .: •_, „k. -. ..v.,,.,-; ,. • howmiaquvolmostidaio.hooroolowsooriildfieilth ''. -.!. , -.' - „.. .:- Cie* -.. - TfillIenOrlijkili -• , ..r-, 328°01sjitallalVilniealitfliontssfteld L . : / " ' . 2-*...,: 7., caa" J.imee,f, ....„.