The URL can be used to link to this page

Home My WebLink AboutBLD-20-001222 ,/01,YRR Office Use Only `r Permit# ,yy OH -,O ', . Amount cts.MTTAl M [S q0,,,°�s 662? Permit expires 180 days from issue date 13u -at}-iaa7- EXPRESS BUILDING PERMIT APPLICATION �^ C +� D TOWN OF YARMOUTH r __..___....i Yarmouth Building Department ¢ ` SD' - ,} `inioi 1146 Route 28 i 1 South Yarmouth, MA 02664 1 ___- (508) 398-2231 Ext. 1261 =�-a- _ _ . CONSTRUCTION ADDRESS: l'' V.r..<y�„Q C-4-- . 0 3 ) e'��f ASSESSOR'S INFORMATION: Map: Parcel: OWNER: l) .SSlib `>....." C ) 3..)._E' -7iv, NAME Mike Mc l t'6rel structi,:A TEL. # CONTRACTOR: PO Box 52 NAME West tharinaissribLess02670 TEL.# Cell (508) 280-6964 esidential ❑Commerci SL-58633 HIC-1(i943933t of Construction$ 1`C - Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) � ❑ I am the homeowner 0 I am the sole proprietor 3/ihave 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: X C` Location of Facility I declare under penalties of perjury that the stateme h in c • d 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 'c n d u Ha under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: ) /' I I Owners Signature(or attachment) / ► f-"k`LSD Date: r' Approved By: l ��—Date: � �� Building Official d ' ee) EMAIL AD SS: Zoning District: Historical District: ❑ 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 Envelope ID:F78684A1-2918-4383-874D-929FBF640F10 "o 32S 32-Jo RISE ENGINEERING- , -E D ( `s& P` L( OWNER AUTHORIZATION FORM I, Thomas Boggiano , (Owner's Name) owner of the property located at: 8 Vineyard Street (Property Address) Bass River, MA 02664 (Property Address) hereby authorize McCarthy Construction (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. comet° DocuSigned by: -.4%0S boOait.o Siggnature 8/29/2019 I 6:57 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 • = h ie 51 Department of Industrial Accidents : y1i_o 1 Congress Street,Suite 100 • ='Jf=i • Boston,MA 02114-2017 • 2•, ,rcf' 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 : r,c. Address: PO Box 52 - - City/State/Zip: - ------- Wes>� �°°i : b76-- _.�_. • Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with i(- employees(full and/or part-time).* 7. New construction 2.0 lam a Sole proprietor of partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.]• • . 3.01 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. CI Demolition 10 Q Building addition 4.01 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.❑Roof 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 S►., 1 /+ 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. 2Contractors 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 andJob site information.. ,�• Insurance Company Name: Jc.-4 'cn..I Li cJ ; i 47 + I ►IC T.�C Policy#or Self-ins.Lie.#: V q k/C R-`I 3 531 Expiration Date: I'a-)• ►(1 l Q 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$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 /nss/ 'mollies of perjury that the information provided above is true and correct Signature: Date: 1 )rfl t F • Phone it: ,0 )-i-u'(,fGy 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 Cleric 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Y-4 Fo_./7bwo-,w,1ead.10-/Office - 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 ..rze ge20/7/79201 .V._ZeljeSae.41.1€1.4 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 .409393-r----;.,,_ 06/15/2021 1000 Washington Street -Suite 710 MICHAEL MCCAittRYI 2 if, -- ,' Boston,MA 02118. • / -- / ...--- ' '1 ' - --: 'MICHAEL F.F.MCCAR*017: /2 /, / Li i: / 1/ if-- • 6 RANGLEY LN. . - , i„,•,,,...0(a r.a4.4: SOUTH DENNIS,MA-02660 :•Undersecretary Not vairthii out signature E. COMMON ,.40•7, V Division or 11---claZi iti_eithusetts Board r 0 Building Re., - —ensure • Michael 1010Cluthy 10 yremons and Standards Constrod66 • fairteartity Constnisilon „.s.- - idtPrvisor . 1 CS,058633 ' MB aucaillAWY Conligeted thellational Nor' .:- , ‘-...•-r •1110...t '—: -,i •••=r ,. 771110#4 OW 1,,,,,4 0 . 2314dtiy PO of August 2S11 . • iliexs2 -....., • _.14 - — — * -:;' WEST DeNNISItA •-,., ‘s- a • reikneareAL MIER NW NIMINNINNellillelid ' ...........4e........s...........• Commissioner az. ‘ . tromtumaps...... - _• _ . . s .. OSHA 001558712 • • , ( sbillatft ment • • Cle411111.1.41.0411ffqietCetarninee " ' - U.S.Depart of Labor ,..., , ..— Occipalkonaffilalety and Health Administration wietageoretear4 Michael McCarthy .., _ . . . - Patedwift hasThseaad - ..,! ;1 ' • — . .. ,' f' . ftd$1.:11;4.. ."••••-•-•—•• 4. • - , .. . . -0,............z.- =• • . . , • Poo . ......, . . . .„. . a'"