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Home My WebLink Aboutbld-20-001820 i CPermit# v F` `� \' ��.Tr n s Amount 3 13 2u� r ` Permit expires 180 days from . l L issue date EXPRESS BUILDING PERMIT APPLICATION OCT 0 2 20) TOWN OF YARMOUTH Yarmouth Building Department 60%na 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: (` (44- S R f LI v,,,)-L ASSESSOR'S INFORMATION: R--/ Map: l Parcel: OWNER: (,-- /1.-v-1b S�.r.1 C (r-4!) 70--Ssi ok NAME Mike McC aPftly1CAVAIMi'UCtic11 TEL. # CONTRACTOR: PO Box 52 NAME West DettiatsAlt ti267U TEL.# esidential 0 Com Cell (508) 280-6964 nSi .-58633 HIC-16933 Cost of Construction$ )&x: Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) 0 I am the homeowner ❑ I am the sole proprietor I 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 ter Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: 54-',7 . _vCV Location of Facility I declare under penalties of perjury that the statements herein contained 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 revocatio f my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: 4.4 C-E, y Date: )v /Z b S Owners Signature(or attachment) Date: ,o L i/r Approved By: _- Date: ! -'7'f Building Official(or designee) E L 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 40ft Permit Authorization mass save Form Site ID: 3704721 Customer: Paula Murgo I, \X�CT c ty ,owner of the property located at:e-al. (Owner's Name,printed) 9 Bakers Path 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. V Owner's Signature: � •. P � IP 7 Date: C -3 '0 J • * 4 t,*V e1#e#0000000 0 000 e0V 000000000 0*04R 000 .00 0 FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: Participating Contractor Date Name: RISE Engineering Phone: 401-784-3700 Email: Page 1 of 1 For Office Use Only • The Commonwealth of Massachusetts _,: i_Gi Department of Industrial Accidents • _ielill= 1 Congress Street,Suite 100 k. a • Boston,MA 02114-2017 .�.,4;‘- 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 Address: PO Box 52 WCity/State/Zip: est s V� -- --_ __— - none Pt: • Are you an employer?Cheek the appropriate box: Type of project('required)• I.Q I am a employer with 1, employees(full and/or part-time).* 7. ❑New construction 2.1=I I am a Sole proprietor of partnership and have no employees working for me in 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 10❑Building addition 4.0i 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.❑Electrical repairs or additions proprietors with no employees. 12.0 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 c. 14.[ then �►'.),tis i . 152,11(4),and we have no employees.[No workers'comp.insurance required.] • *Any applicant that checks box 1I 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 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: Nc,'Ff,..n, Li c.)›;) 47 1 c• Policy#or Self-ins.Lic.#: V 1 k/C.3'i 3 571. Expiration Date: 1',•-)►f'l7j 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 ns,ey enalties ofperjury that the information provided above is true and correct Signature: d Date: I ) !t F • ' phone#: @,k) a(o-6 4G c> Official use only. Do not write hi 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-n?,,,,n6tila-/ 4- Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Individual MICHAEL MCCARTHY Registration: 169393 P.O.BOX 52 Expiration: 06/15/2021 WEST DENNIS,MA 02670 - Update Address and Return Card. SCA 1 0 20M•05/17 ,n (ffy,,,,zniuvea ig/✓Zia ae i4e(6 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 1-6939 - 06/15/2021 1000 Washington Street -Suite 710 MICHAEL MCC RTHY — Boston,MA 02118 • J__-- MICHAEL F.MCCAF • f ' t' ` //A- _6 RANGLEY LN. it ' a 1 ,NOt V811 signature SOUTH DENNIS,MA-02660 Undersecretary `. g .r Oa OAvlteaitih of at: ut etts DiirIsion of Rr Eh ., tilt Board of Buitdi sNQaaL Litensdfe Coast and Standards iM sthy . • r CS-088633 ;;` 23 dllgrOf Awed 2O11 . News.J .y Pip BOX62 ,•. •; 11810,Ndlesdaber, a-- WEST:i MA s;� - if%. ., .t NATO sitAL P IR er a Ai— . 1 Net nelrlfaattraembsanit • ....,.. .m0. ...c.....,.,,.-� taiticat . 4Wilt1l4sawtar. OSHA 001558712 y _ h ,, alafillgaii , ooapagonm Salety end Health Ad on . :: ire . Michael ilcfar#hy . MIhaw‘uRCOMIW011diPididd a10+10oro otatseffAyandtla>asi T fh 3�t1 7 i . 4. «titedatainemsys a e/9 _ _._.--jai.MAMt+w Ilw�rs.W A.i-MmwKt►fiNW: