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Home My WebLink AboutBld-20-002212 • ,, j Permit# NATTA '. csc 'x �.� l.. �� ;jAmount a....k.^� d 1 _ ,�j� i Permit expires 180 days from D f E PA R .V U l issue date By _ EXPRESS BUILDING PERMIT APPLICATION�a U D-D--I TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 Ac. (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 7i cc ) AvtV"ASSESSOR'S INFORMATION: Map: Parcel: OWNER: / l''-Le. I AA(c.\-IV r--\ S,w•<,_ CO -) - v r 7 NAME ✓like McCarthystfi rI TEL. # CONTRACTOR: PO Box 52 NAME West Dernn l�lQANg70 TEL.# Cell (508) 280-6964 ❑Residential 0 Co erciaJ58633 HIC-169393st.Cost of Construction$ )SGc- - Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) ❑ I am the homeowner 0 I am the sole proprietor L/fhave 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 1/ Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: S 4') 9lCc) Location of Facility I declare under penalties of perjury that the statements herein cord e 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 license and se iqn under M.G.L.Ch.268,Section 1. Applicant's Signature: j,� /�` )` I�1 )f f j/ Date: / 1/ Owners Signature(or attachment) X Date: l�11 1 /t( Approved By: 7✓ Date: /47 . Bui g O al(or designee) L ADDRESS: Zoning District: Historical District: 0 Yes ❑ No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes ❑ No 3 1 'iS 2-4S1 RISE - ENGINEERING'" OWNER AUTHORIZATION FORM 1, MICHAEL V NEEDHAM (Owner's Name) owner of the property located at: 98 Acres Avenue (Property Address) West Yarmouth, MA 02673 (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. Owner's Signature g/2 /7 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 = •••—= i / Department oflndustrialAccidents • _EeY110 '� 1 Congress Street,Suite 100 e _ W Boston,MA 02114-2017 www.mass.gov/dia 'Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. • TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information McCarthyPlease Print Leeibly Name(Business/Organization/Individual): �McC L.Gr.54-irs-A-4T44..r. Address: PO Box S2 - - City/State/Zip: _ ------- Welt lnnoneis1V A O26.0— - _Are • you an employer?Check the appropriate box: Type of project('required): 1.Q I am a employer with ' . employees(full and/or part-time), 7. ❑New construction 2.0 I am d Sole proprietor oi 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. ❑Demolition 4.01 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.❑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.t ❑ p • 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.[t.]6ther �►� ��#,. , 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. tContractors 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 provldingworkers'compensation insurance for my employees. Below is the policy andJob site information: 11 Insurance Company Name: /C.+t'c.n� Li ,;Ii4•-/ k F t%rc. Tnc Policy#or Self-ins.Lic.#: V I k/(---4-`I 3 531. Expiration Date: I' .)ICI• i 9 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 bya 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 'nsso,y 'enalties of perjury that the information provided above is true and correct. l% Signature: Date: I)-)+fI I F ' ' Phone#: (Sc.t) ah-GICy 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#: , 4 ro-nw-i?,0-/-to-ead16>z° 4- Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, Massachusetts 02118 , Home Improvement Contractor Registration L .. 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 fie? Kwimorierfead(6/./ZaWa44kielk 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: Realstration Expiration Office of Consumer Affairs and Business Regulation 4,69393.------..‘....-, 06/15/2021 1000 Washington Street -Suite 710 MICHAEL MCCAiti.W----;-4-4-‘1,!, Boston,MA 02118' ' /..---"-- . t MICHAEL F.MCCARTH'( /--: : g i'1/ //7 ! _ i 6 RANGLEY LN. • : --• -- :.4.4tAit 4 rae.40.4* SOUTH DENNIS,MA-02660 Undersecretary .'../ Not valid* rout signature c - •=:".-77.-----------'------ --............-___,........,........4,001yornnioisio"• nnowerpraidice.at_Massachusetts Board reastanal Licensors of Bulld 1707-1 prvi 7141 oat and Sta Wards 1 if • 'AMMO MeCarthY 4 Constr. litt , INICarthy Conotruetion ...s.. sor i ... ' Kali SUCCOPAIDY COmpieted CS458633 the flakind Mir• ''' ---- . gcnirreg,: ) .,,... , , • Erl day Of August 2011 . : mialiAtt.J ,..,, : - •? Ate 5: PG!lox s2 - • *4E'-. - * : . . -- -:•AO .a WEST DENNISMA ; . •NW Ntionollifbar, . : .f, „ -,r•VY ' Obsalerailliso Niro:flaw,.MOIR 1. Notralitraisatioessed • • .,.................p....! CorrifttiatiOrter 1 . tomm„............ :......,:._ .. -.7 .. ---...-.- OSHA 0015-58712 • - - , -- - " - 'Waal Cyr 41141161.411**Atalight , • ; - - • GOMM** :: I. fi --: U.S Osparbaont of tabor ' 4,....: Occupationaltalety aro maim Administration '.t4: - . ... •: ,...,. Michael McCarthy ';. . . - :,,... ,,,.. . ... bespax...umfrompiefolvileur. oepopi"-orsoovind-.....----- TrOrngC0i#Orf' ' : Etoolkiteloos ' ' • . :‘• -' - --: - , - • PI* -.,. ' . . , •