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Home My WebLink AboutBld-20-002491 1 m-•Yiti `vLLU.. use vuly r" `� Permit# �`t !' O' 9 . l y! Amount MATT M ' ITT u+�36". Permit expires 180 days from 21)— 1 Ct( issue date 13. EXPRESS BUILDING PERMIT APPLICAT C E I v E 0 TOWN OF YARMOUTH Yarmouth Building Department OCT 3 0 2019 1146 Route 28 South Yarmouth, MA 02664 Bu' 'cp/ F ,- . (508) 398-2231 Ext. 1261 ��. /— _md.. CONSTRUCTION ADDRESS: 5 1"C tJ ( \4-c I L T" (A. ASSESSOR'S INFORMATION: ' \ I ' Map: Parcel: OWNER: Av4, ,r,t W.-44: I NAME Mike McCarthy ifi u$ n.. TEL. # CONTRACTOR: • 1} PO Box 52 1i NAME " West Dennis, INI gi SS TEL.# /' Cell 508) 280-6964 ®'ResidentialErSTILIg8633 HIC-169393 Est.Cost of Construction$ I 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 V Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: .4 , e.v`' Location of Facility I declare under penalties of perjury that th emen he in 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 prosecution under M.G.L.Ch.268,Section I.Applicant's Signature: Date: (v1ry 1.s II Owners Signature(or attachment) AL L L,J- Date: Approved By: y C/ Date: /o i "F Building 0 al( esi ee) E L ADD SS 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 DocuSign Envelope ID:026CD4E1-C29E-4ED4-A2FB-49A39C8F62D7 5�g 2 Z1 6 -13 r RISE \wit c, „ sc„ ENGINEERING' OWNER AUTHORIZATION FORM 1, Andrea Worrall (Owner's Name) owner of the property located at: 9 Pequod Circle (Property Address) Yarmouth, MA 02675 (Property Address) hereby authorize McCarthy Construction (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: efrf1ature 10/8/2019 I 10:21 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 ,9-4 ro-/7-6,-740-/-mpeadlo/ 0,-,).J.aaeie4e/4, Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement-Contractor Registration Type: Individual MCCARTHY Registration: 169393 MICHAEL P.O.BOX Expiration: 06/15/2021 WEST DENNIS,MA 02670 Update Address and Return Card. SCA 1 0 20M-05/17 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 169393- _ 06/15/2021 1000 Washington Street -Suite 710 MICHAEL MCCAI T-HHY ? Boston,MA,02118' /� 'L!, MICHAEL F.MCCARTI ( j, ,. , i/ 6 RANGLEY LN. 'a./ f SOUTH DENNIS,MA 02660 Undersecretary Not valid witfiout signature _.......: Oi"' iititni°nraitltt68sfiteits Tieeare• .. SiOh8f feai Boar Buildiag Re ' �olaf iottsd *Wards: Cona1<r j- off,rvi aor leas su eernpistid dre Mional F 11633 .:. Colltiose?adrift come - °day etAlii11 . . MICHAEL . + ; PO eoxi ; '- 4""iir;WINOMINSIEMber. a . ,14‘,..:431/4.1.4... . I.. Not valliferefsesembeseeI d .• aYamrf a - NATIQNAL mein ' • COfr1Missiotor „r5,.mk..4.4........ . , ...• .. . _ .:. • _ . .....,______ osHA 0015587- 2 , us. Safi y end Haslet M Labor , :• Michael McCarthy -.. .: 1 1, + suge rrcl mpl om cie4,rooa r.*, tsdmand*ig i ttiiiiea�, TraMinQOatil r sis8atirli o ,t Loutsor geld X,'. ! ,R :si • S mil Y., T.. ia.**itmoi,„ • The Commonwealth of Massachusetts t" ��-4'/ Department of Industrial Accidents • 1 Congress Street,Suite 100 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 /�,� Please PrintLegibly Name{Business/Organization/Individual): MichieI fiCa thy Address: PO Box 52 - - City/State/Zip: ---------West Denni2b�• one — Are you an employer?Check the appropriate box: Type of project(required): I.11 am a employer with _. employees(full and/or part-time).* y. New construction 2.0 I am a Sole proprietor of partnership and have no employees working for me in S. ❑Remodeling any capacity.[No workers'comp.insurance required.]. • . 3.01 am a homeowner doing all work myself.[No workers'comp.insurance required)t 9. CI Demolition 4.01 am a homeowner and will be hiring contractors to conduct all work on my property. I will 10❑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 Tam 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.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.[ ther Sr,��•i . 152,11(4),and we have no employees.[No workers'comp.insurance required.] • *Any applicant that checks box#1 must also fdl 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 and job site information: Insurance Company Name: Ncjic,n,I 1_;c,;1;47 + / iC rr•c Policy#or Self-ins.Lic.#: y q 1k/C-3-`1 531. Expiration Date:• 1'a-1►t r l 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 punishablabya 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 ns04, 'enalties of perjury that the information provided above is true and correct Signature: Date: i,- 'CI t 1 • ' Phone#: @.k)_ -G IC y Official use only. Do not ivrite 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#: