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Home My WebLink AboutBld-20-001225 :yRii Office Use Only 7 • e Permit# ;., ,firy. c. O 'l, . y .Amount . �� '=F` MATT n ca ' *`°'" "°"�Endx' Permit expires 180 days from *?'::"'' ',issue date Bu)--zo--/asr EXPRESS BUILDING PERMIT APPLICAIf I C �= 3 I ' TOWN OF YARMOUTH s i Yarmouth Building Department 1 1146 Route 28 S �� d 1Q South Yarmouth, MA 02664 i r (508) 398-2231 Ext. 1261 .�_ ,;. % CONSTRUCTION ADDRESS: 3 /L f 0,-, ...-r ASSESSOR'S INFORMATION: Map: Parcel: OWNER: ( v'�. cd k..),- S r �G 1, G Y �/"714-/t r NAME Mike 1e It I iiStri eti+,;:. TEL. # CONTRACTOR: PO Box 52 NAME Wes impso*A5Dmi 02670 TEL.# Cell (508) 280-6964 esidential 0 Commercial CSL-58633 HIC- 3f Construction$ /("4" Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor Li, 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: S ' T €'&tc) Location of Facility I declare under penalties of perjury that the statemen e n t ' 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 my ' under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: ' 11 C 41—R Owners Signature(or attachment) c L"` Date: Approved By: Date: 3 /7 Building 0 all desi ee) E DRESS: 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 DocuSign Env lc_ 9229 C5 i-EA 8-;311-AOFA-DA3 : -81?1=F /OM Permit Authorization wog Lp i 73 tl y Savings through energy Ethetoncy mass save Form c6ti /0/2 34'C G " e- z2 Site ID: _ .562€: Customer: Craig Johnson I, ,owner of the property located at: (Owner's Name,printed) 7 L r ye South Yarmouth, MA 02664 (Property Street Address) (City) hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed below to act on my behalf and obtain a building permit to perform insulation and/or weatherization work on my property. -DocuSiigned by: Owner's Signature: \-5619664f Do4P456 8/1._ 011 i 4:38 EDT Date: FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: Participating Contractor Date neefng Pac : 1 of 1 For Office Use Only • . The Commonwealth of Massachusetts • Department of Industrial Accidents • 1 Congress Street,Suite 100 Boston,MA 02114-2017 04' 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/Organization/Individual): Michael McCarthy CGr 54--v- ,i-v.. Address: PO Box 52 — — City/State/Zip: -- ------- West ilV,�)2b76 • Are you an employer?Check the appropriate box: Type of project(required): 1.Q I am a employer with employees(MI and/or part-time).* 7. ❑New construction 2. lam a sole proprietor or partnershipand have no employees ees workingfor me in ❑ p �' 8. ❑Remodeling any capacity.[No workers'comp.insurance required.). . • 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. Demolition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 El Building addition • • ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.0 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.t • 6.❑We are a corporation and its officers have exercised their right of exemption per MGL e. 14.[ 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 slate 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 and fob site Information: Insurance Company Name: N/�+'t'c.n,I L c�i I i�/ k �ic.i V 1 c . Policy#or Self-ins.Lic.#: 1 k/C?-y 3 Say, Expiration Date: 1 i(I 17 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 by.a fine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 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 its 'enalties of perjury that the information provided above is true and correct. Signature: ' Date: I 1-I'fl I F ' Phone#: mot;) ? o-G SC b 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#: .9-4 Fo-/-,4m61-/mx.teeice-/OfficeOffice 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 WEST DENNIS,MA 02670 Update Address and Return Card. SCA 1 0 20M-05/17 gr, ....6, ,,x,..4,4..,...4.,./..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: Registrationk Expiration Office of Consumer Affairs and Business Regulation 1693 .93_77,--'.:.,-.,- 06/15/2021 1000 Washington Street -Suite 710 Boston, . f MICHAEL MCCA -1Y-* MA 02118 ' ./...------- / •••-• .- ---,,,— • , . t..! / MICHAEL F.MCCAF444Y-7-77;, g ,.// i/' i / 6 RANGLEY LN. , •:, ---- - .4.,71,011 4 ra,(49.4- SOUTH DENNIS,MA 02660 .:,, Not valki-vi 'out signature Undersecretary ,47: irt g"int"CilidenneralthProreaCZ"Sat aLCIPIRttS • • • Michael Mcdatitly 1 BOard or . ellstfte Building Rardations and Standards ConsIsstiotktifittpe7tvisor akiesslisy e Cnalinsettols ! CS458633 , Has seecesidadb taiMpistedtheNstional Fiber' _-• .. -,:f ,.1,,r ,_ 4131gretg Colitdess Tiskdrig Wiese , ..-7 . '.-•-: -:.,.:;.- 041 C- ' -'*: .,. . 1PO Erldity of August 2011 . 4001fAn.Jiro ,:,- -7t:---it' -,-. • ..;.-- . Iry : :44 , WEST DENNIS ,-'7,*•.,:-' ..c-*: —.1,1or_L._ •"*#, ‘ ; ' .Vaaktailltimilthar. . .(4... ..43,.-0.,- : Illmelereftie NATIONAL masa -. • . NW viitodirtmeboisse ' weirmegt.wede.ComeNrpo.e. COMMillakitter 'az .410.--- t„..5"mtisiagarkfla.... • -. ._•. .. • - • - , . - -.-, i,.. . ,- .' : .... _ Y- . •.;:. ., 7 , r . , osHA 001558712 • 1ii.040-44,*tioorwesdcz. U.S.Oeperiment of Labor Occupationalialety ond Health Administration Wti Of*45kfirgy.• •,..: z ..-.: Michael:McCarthy .. -:.- - , : -. -A.:: • -. -I:-.:.'-..i. ;.. , . ,.. .. : ..,.. , . coo ,-..::-.,, •••.0,14, .- . • •-•,, 0.411.*91**40/10000.0E-1071VOr OccxiS!aanik1staatyaiidtiso'al ' ' • • . - ‘"°47 Tlaffiln0.00i*10',7' ' ' -' . - '' : .: . 7-z 0.2wwiteallaillaie ilia inciattaftekt., y:;•- • 0/9101 •: ,'-:i: .'•ridf ...-,w — •;.4 .-i‘...ii, ._ ;:_-,:.-`- -..-,_ • • (C)41.) - .