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Home My WebLink AboutBld-20-002490 .O1'.y9R vuicc use vwy • 7J .. 4 S1 C Permit# 'Ou. - '� i Amount 3 G MATTA°"el 5. 4� 1 °" "`°~Q:C ;Permit expires 180 days from - i issue date (3Ck)_w 2,L q 0 EXPRESS BUILDING PERMIT APPLICATIONS C E € V E D TOWN OF YARMOUTH Yarmouth Building Department OCT 3 0 2019 1146 Route 28 South Yarmouth, MA 02664 B u i - w�' _ (508) 398-2231 Ext. 1261 By ' �r�" `� / CONSTRUCTION ADDRESS: / v 7 h,:., 4: /C_,t/ (Q 4 ,,d,,_l G., ASSESSOR'S INFORMATION: 1 r( �, 1 Map: Parcel: V OWNER: 1c..iLv•L 'r:.itkci.hiSl. S.."' L f.wG- Lt" t-TV? e NAME Mike McCarthy eitaistrataften. TEL. # CONTRACTOR: PO Box 52 NAME West Dennis, MAIWKOMSS TEL.# Cell (508) 280-6964 N Residential ErS°i mg$ii33 HIC-169393 Est.Cost of Construction$ 1 S-'' — Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) ❑ I am the homeowner D 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 r-- *The debris will be disposed of at: .-1. , e.-Ac c., 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 revocatio li e prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: Ivh.' II Owners Signature(or attachment) p4k L. Date: Approved By: !?ts� Date: /0`—.G' "7/9 Bui ' g ial( r designee) EMAIL ADDRESS: Zoning District: _ Historical District: 0 Yes C:E No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes E No t."1G '431 33 7( DocuSign Envelope ID:573C2313-EF31.4718-A5E2-04D6BB8DDC15 SF— 2_1-2 gc``1.u* RISE ENGINEERING' OWNER AUTHORIZATION FORM I, Victoria Krukowski (Owner's Name) owner of the property located at: 467 Main Street (Property Address) Yarmouth, 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. coomitiecusvned §nature 5/30/2019 I 7:57 PM PDT Date RISE Engineering, a Division of Thielsch Engineering, Inc. 5 Dupont Avenue I South Yarmouth, MA 02664 1508-568-1926 www.RlSEengineering.com �� ) 2 /M Ie 1 y' h 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 MIC BOX Expiration: 06/15/2021 P.O .: WEST DENNIS,MA 02670 Update Address and Return Card. SCA 1 Cr 20M-05/17 /e Wemrieniuveal.. a/✓ZZawac.6.Ae 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 1-69393_ 06/15/2021 1000 Washington Street -Suite 710 MICHAEL MCCARTHY -- ,; Boston,MA.02118' • / �"- i - MICHAEL F.MCCARTHY � j 6 RANGLEY LN. 'a j - l� SOUTH DENNIS,MA 026fi0 Undersecretary L. Not vaitttiout signature Ca—clnvxeakh of if Ma55.ChUteff Oii/Itiion of protesstixnat Libansdite Michael• McCarthy y Board of Buitding i is '-. g Nwtt and Stalid�lyds 1 C.es4Ya16ion Gona;r . Nee the l i CS- 86 �leor ' OsIkdoee t sae . : . Fi -. cif August 2011 NORM.J J L - i .. WEST EPI -.' ,`I ,girwllff�Mr4 .14„,;ra � � oOrofwlL NATIONAL FIR#R .e Commi fr t./' ► ` s s{ OSHA 0015-58712 • . t4iR U.S.Westmont of labor a 1'f! `' - Michael McCarthy .` 1 , +?odfr o,fi$st.da IO.M4o► :Safer 5fl f N+ a :� Tralhin0 CouiO4 fh- anise . ,. . �` 8bouttorffeFit k " . • _ The Commonwealth of Massachusetts l" "'�—�/ Department of IndustrialAccidents eYll • � 1 Congress Street,Suite 100 c tC a� = • Boston,MA 02114-2017 • wwwmass gov/dia • Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. • TO BE FILED WITH THE PERMUTING AUTHORITY. Applicant Information McCarthyPlease PrintLegibly Name.(Businesslorganization/Individual): Michael Ma Address: PO Box 52 - - City/State/Zip: - -------- Wesini V�Zb7�— -- --Are • you an employer?Check the appropriate box: Type of project(required): I.Q I em a employer with '(. employees(full and/or part-time).* 7. El New construction 2.0I am d sole proprietor of partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance r quired.]• • 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 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.* 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14. then Sr 152,§1(4),and we have no employees.[No workers'comp.insurance required.] • *Any applicant that checks box 01 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 mustattached 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.+'t'on�I L ci ;I i 47 •- 1 'rt Policy#or Self-ins.Lic.#: V I w(.-•`)3 S-71 Expiration Date: I'a-)iSrl 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 punishablebya 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 ns jl s enalties of perjury that the information provided above is true and correct Signature: Date: i)-)'fI i F. ' Phone#: (jcit') A u-(f C 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#: