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Home My WebLink AboutBld-20-001815 1 ft • ,$' . , t�! Permit# 40 C's O . .1t411 l•'� . H: iAmount, .N Maa.m'"°4p,mod 1 'Permit expires 180 days from ;.:..: i issue date..: 3u —zLlig EXPRESS BUILDING PERMIT APPLICATION 00 ,) '019 TOWN OF YARMOUTH Yarmouth Building Department , C 1146 Route 28 3�, South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: k' ft+ SSt\ t Y--sio,;— ASSESSOR'S INFORMATION: Y Map: Parcel: OWNER: } k''�rti?,—r.-. Prat►. -+ tL �7y _ S'1•(-��{4 NAME Mike McC #i-ucti, TEL. # CONTRACTOR: PO Box 52 NAME West DemfigvMjA1 S670 TEL.# Cell (508) 280-6964 esidential ❑ComrrrsrsiaL-58633 HIC-1693 Cost of Construction$ I la' r Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) ❑ 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 if Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: S T'7 -e)((v 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 I. Applicant's Signature: ' CC�� Date: )V /3 11 S Owners Signature(or attachment) ///" �� Date: it., LI_ i/ Approved By: Date: / — %p Building Official(or design) EMAIL ADDRESS: Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No ❑ Yes -, No DocuSign Envelope ID:27AC7FBE-8F8C-4223-9BBF-C4F343810718 .-- 7 qZ c/ Y - T, RISE " _ 5-5-c - ENGINEERING OWNER AUTHORIZATION FORM I, Kenneburn Properties Inc. (Owner's Name) owner of the property located at: 186 Main Street • (Property Address) Yarmouthport, MA 02675 (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. DocuSigned by: LUs B3D3D1415987459 Owner's Signature 8/22/2019 1 3:49 PM 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 t " i �/ Department oflndustrialAccidents _E:Y1l • o w 1 Congress Street,Suite 100 • 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 ice f 1Please lPrint Legibly Name.(Business/Organization/Individual): Michael McCarthy Address: PO Box S2 City/State/Zip: • West Df?nlne , bT0 • Are you an employer?Check the appropriate box: Type of project(required): 1.EI am a employer with 'S. employees(full and/or part-time).* 7. New construction 2.0 I am a sole proprietor of partnership and have no employees working for me in 8. D Remodeling any capacity.[No workers'comp.insurance required.]. . • • 3.01 am a homeowner doing all work myself.[No workers'comp.insurance required]* 9. El Demolition 4.01 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.* • 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Ether 1-1-%>.)�� . 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. *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 job site information: Insurance Company Name: Nc,'Ft',,n,I 1-cbi 1 i•I7 + 1 'Wit: "1—,-,c• Policy#or Self-ins.Lic.#: V 1 k/C-3•4 Sly Expiration Date: I' -1►f'i 7 • 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 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 ns y- 'enalties of perjury that the information provided above is true and correct. Signature: Date: I I'rJ 1[. Phone#: .1-to-6 IC c, 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#: K70/7?, meadia-/ 0,-Je)adeeJe/4_ 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-05117 .9110; Wewunewevag,/ityl._//47,14ae.,‘Ase/k 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 1.69329 _-__ 06/15/2021 1000 Washington Street -Suite 710 MICHAEL MCCA.:TAIW:: -.71 Ell.-1: Boston,MA 021184 .•-• / ,/ t..1 / MICHAEL F.MCCAFT64Y:7-7 ' 72 • i.' / // i /, •, 6 RANGLEY LN. , • --- -, ",..„7„,,,(4 1 zeisto4 ..',•SOUTH DENNIS,MA-02660 . Undersecretary i, Not validAiiittiOut signature ", ail lie_•',;• -• Ilitemithy 4s -eec . . . Cmirancirsw: dth-e-os-sfiMW-oasa-issi-a1-c-n-h-u-sX-e"i.:.s Michael McCarhy i Boarcrof;ulidingRegUltti : d • . :ns:itoiiu " ardins Cdton ttp,rviso7 CS=058633 ' Nes sussisiii*Stespistiel the-aft/nal Ma' . •-•*; ...,: .*:: ::-. :,., .. Alynces4et,,•,.., :,.,. , Csiltdoss tisitgne Coyne F7 47--,..-'Jt. ri , , ..* 23I4 dsyStAiejust 2011 • , nowt J ,t,'.WEST Ofteglmi • 4.1.r . ; . um,elmaribar Mtemereelliss pakropstioa.mein . NM vidlifixdassembeesed • ................................,......., ' Commissioner I . LARIntmearay.t•• ..., -, - . • --• . ... . OSHA .0 0 1 5-5 8 7 1 2 4$0, .• agaksbegiftur--ecip,,,,fr-a.swito„,:„ . ...: ., , ,:..,:-.• . 0,...., . . - _ florgiorgrookt , • . . „. . .. U.S.Deperbnent of Labor .., Occupalionaltatety Wid Health MeninistratiOn s: :Waal-Ofeekr44 _ . .. ,.. ,. Michael McCarthy .. • _. . . • . _ Aro- ...4= 1 .. ._-./sgswxyroweis"104,00,Qcputraww:gaiotandtioash =t .. Takin004#04— ' _, 32.Boteiblelest . , : Itelesindishoustafteltittkee 4:; .. .';' • - ' ' .:..•.-- .: ' . -' Oglalthr—- — • ' ' .: 1.' -• . f. '-; -s'.''. ''.- • ; '.'. .:... ,_ . . . - r• - •