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Home My WebLink AboutBld-20-001819 ua v Litc9- 'Pennit# �A -Amount Permit expires 180 days from al 1 E'I . sue date EXPRESS BUILDING PERMIT APPLICATION UL! ' 21 s1. TOWN OF YARMOUTH '/ Yarmouth Building Department CC." 332 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 'C) -1l,.._ i.,,e- e-)- ASSESSOR'S INFORMATION: �^ Map: Parcel: OWNER: C y h c-4c7 N "ZVtr �i(1� '7tir -.7G1/4( �7/5 Mike McCatitirejiiMtuctiwn TEL. # CONTRACTOR: PO Box 52 NAME West Demallsr4Ar2670 TEL.# esidentiat 0 Com Cell (508) 280-6964 —58633 HIC-1693 3 Cost of Construction$ 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 V Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: 54-',5-- - 1)(('0 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 revocation f my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: -}- L1• 1./Az ( f Date: )0/i f/S Owners Signature(or attachment) Date: 11. '/f Approved By: / BuildingOfficial(or designee) !/ Date: /a —2 77 gn ) EMAIL 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 "?fir --284 Permit Authorization mass save Form sz, to 3 s , Sa•,,ings t,,„uce ern,,,, e W'.c kN n,-; Site ID: 3634515 Customer: EYNSHTEYN AVERBUKH I, y () S 1,4 e yr) /q V"er 644 ,owner of the property located at: (Owner's Name,printed) 20 Thatcher Road 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 b 'Iding permit to perfor 'nsulation and/or weatherization work on my property. Owner's Signature: (� Date: 1J I LI— )9 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 Rev.102015 • ' The Commonwealth of Massachusetts • ► hGI Department of IndustrialAccidents • F _i:ylio- 1 Congress Street,Suite 100 • Boston,MA 02114-2017 • z,�„ www.mass gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. • TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please{Print Leeibly Name{Business/Organization/Individual): Michael McCarthy .S'�r�T v�r� r�C. Address: PO Box 52 — - City/State/Zip: ----- --West nl�ViAb'1�— -__-__ • Are you an employer?Check the appropriate box: Type of project(required)' 1.1El I am a employer with ', employees(full and/or part-time).* 7. D New construction 2.0 I am a sole proprietor of partnership and have no employees working forme in 8. El 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 El Building addition • - ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.0 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.[ thee S►'‘)l)•t+ 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 subcontractors 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 provtdingworkers'compensation insurance for my employees. Below is the policy andJob site information: ,�• Insurance Company Name: jcq+'t•c._. Li cj›; i 47 k t"►rc. Tr c Policy#or Self-ins.Lic.#: V «4 3 s7 y Expiration Date: i -)I f I!• 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 punishableby•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$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify and t e rosy 'mollies of perjury that the information provided above is true and correct Signature: Date: l 1-1'f't 1- • phone if: (Rt) - u-G tC y Official use only. Do not write in this area,to be completed by city or town officiaL • City or Town: Permit/License# Issuing Authority(circle one): • 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: tip 6_m„,-)-?,o_,-m,oead19/ 4 Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Individual MICHAEL MCCARTHY Registration: 169393 P.O.BOX 52 Expiration: 06/15/2021 WEST DENNIS,MA 02670 Update Address and Return Card. SCA 1 0 20M-05/17 e Wainaaaaarea .. oy✓gaJsa �.Je%G. Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Individual before the expiration date. If found return to: Registration Exoiration Office of Consumer Affairs and Business Regulation 169393= 06/15/2021 1000 Washington Street -Suite 710 MICHAEL MCCARTHY = Boston,MA,021188 �y / i? MICHAEL F.MCCARTH{ // " 6 RANGLEY LN. - - a. 'a 1 • ' s SOUTH DENNIS,MA-02660 Undersecretary i Not valid—without signature —' „.... nvlfeiNth of McSs- hu$etts DivI.sion of p►trfrtssicrnal t:idansE+re Board of Building o McCarthy a ins and Statidards q Construction Ganstr isor ' completed the-National Mir `=t 863 2day of August 2 11 MICHAEL . PO ,4 •; ; . ..-.4m0-7,........—, --,a IMyla,MlAaefl�ir• `�`lr4 ti` � Presioratibiss WAT�ONAL Plana Nra Wostoobswlf Eo�tmi�o OSHA 'Go i 5 587 i 2 4$0, • -s a�srs w..ac , U.S.Wperomentof Labor ° ..1. Oecupetionet•Sslety awl Health Adm6 or► *C • , Michael McCarthy :' h +aa ii.tomple.0*RihOurOcwcsto_1Safetyand.ffeslth .{ agltoarsfi[ loaThrierarlahounrorlobl X � f_.�° _ y. r xr i alaialwdylp;w{r ° _�'" «. (Pab)�