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HomeMy WebLinkAboutbld-20-002502 /O.1r t vuicc vac vuiy Permit# O ."4,1,y H - '� ;1Amount 3S� * NATTA M .�"4 M 4"""'"L3 c� 'Permit expires 180 days from l issue date RECEIVED EXPRESS BUILDING PERMIT APPLICATIpN:ry-- - ---- TOWN OF YARMOUTH '1 I OCT 3 3 2019 Yarmouth Building Department 1146 Route 28 BUT. South Yarmouth, MA 02664 13y — (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: k' K` �« ►-N • AA)/-' ASSESSOR'S INFORMATION: Map: Parcel: OWNER: e.�1...1- (•� L S nt.„,: 3CC-c;iSI( NAME Mike McCarthy n• . TEL. # CONTRACTOR: PO Box 52 NAME West Dennis, lk( tRWAVASS TEL.# ./ Cell 508) 280-6964 ®Residential ES°Lmgg633 HIC-169393 Est.Cost of Construction$ I K — Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor 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 I Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: 4 T e'A(c Location of Facility I declare under penalties of perjury that th emen he m 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 revocati li 6 prosecution under M.G.L.Ch.268,Section 1, gg Applicant's Signature: Date: itiI';, I, Owners Signature(or attachment) Ae1L A c .c . Date: Approved By: ie) ' Date: /� j/ , Build' (or gnee) E 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 3 15 3io© o\ky RISE uwt 3 ENGINEERING" OWNER AUTHORIZATION FORM 1, Robert Coolidge (Owner's Name) owner of the property located at: 28 Chickadee Lane (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. cru Owner's Signature Date RISE Engineering, a Division of Thielsch Engineering, Inc. 5 Dupont Avenue I South Yarmouth, MA 02664 1508-568-1926 www.RlSEengineering.com ,674 t-/-moeei16y4°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 CI 20M-05/17 .91e Wevrirraerupea-Arbyr.Aer.i.4a64se/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 189393------.-..... 06/15/2021 1000 Washington Street -Suite 710 ,Boston MA 02118 MICHAEL MCCARTHY' --- ' . /..----- ., . / ' : MICHAEL F.MCCAFJW r / /./ kievii 6 RANGLEY LN. Not val tttiout signature .-.. e SOUTH DENNIS,MA 02660- Undersecretary i. ev, Ilf DCivinnionweafthi. of Massachusetts Michael McCarthyard or eslaujilldietrtgriressioe atonal Licenser* • thy , 9. ant and Standards . Constratettegf trdprxviso , ikeillethy Cometnsollan , Nee sucetesofUlty eoetpleteditte-National Fiber' ; CS=058633 -- ...:-.• mt. ''-&., .. 4,Pirelt;04M020 , Selleleee Training Goatee r- = • ..: —., POMICHAalitosesj --;.' :4 : ------%.- 23"*yet Augerst XN1 . • WEST teems mA , •.•,,,' si: • ., !Iur.Mak Nalboutiaber. Iii0I . Illresaret-illis NATIONAL NOIR 0,2 • I NW reaftesiessesebsesed ........c........................ Conurriadioner Colt % . %Annus.............. • ._• _ • . . OSHA 001558712 • .• . _ . ! - meniastki.is , ,-- ue.gairr&a.a.,,,,,s4rada., ,....i. US.Osperbrent of Labor " ' - 4141146111_146414610glierCtOirsemea : • 4-' • - , OccupetionstBalety end HealMiociministration .1, - , - ,r--% • ' - 1-: gat:SW*4664 Michael McCarthy . haswpcisikaycnpliftd.1040.focupplaxerSPI0Hrittilealits , .. Tia"ng OW*" ' 32 itOniafabstflmeisidll boursordsigitsse .-z ,• • ,. ,.• •. •4.6,„u,. --:. • —tr..,,ligii.,' ;...'' ., . • • • • The Commonwealth of Massachusetts • I`=� 1 GI Department oflndustrialAccidents • _E-ytil= 1 Congress Street,Suite 100 1 _ • Boston,MA 02114-2017 2, ti www.mass gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. • • TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please PrintLegibly Name{Business/Organization/Individual): MitchaelMcC7grthy Address: PO Box 52 City/State/Zip: • West VIA-02 7 ---- --Ar • e you an employer?Check the appropriate box: Type of project(required): I.I 1 am a employer with employees(full and/or part-time).* 7. El New construction 2.0 I am d Sole proprietor of partnership and have no employees working forme 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 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.❑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 ❑ 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.( thee )J 152,§1(4),and we have no employees.[No workers'comp.insurance required.] • *Any applicant that checks box t{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 providingworkers'compensation insurance for my employees. Below is the policy andJob site information: Insurance Company Name: N�'�t'c.n..I Li r > 1 i 47 + 'F►mot: Trc Policy#or Self-ins.Lic.#: y 5 k/C3-4 3 Say Expiration Date: I'1-) 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 und t e inss ;1� 'enalties of perjury that the information provided above is true and correct Signature: Date: 'I5.4 l F • ' Phone#: @ ) L-0-t IC t.t 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#: