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Home My WebLink AboutBld-20-002497 wilIIX u v Vuly o•1ryR-" . ,k `7'' Permit# s.,Ve C. (p1, y Amount 3s MATT M 3 t°+ crd$ -2,0-2Li CO 'emit expires 180 days from S "G —��GENE ® EXPRESS BUILDING PERMIT APPLICATI I N - TOWN OF YARMOUTH OCT 3 0 2019 Yarmouth Building Department 1146Route28 3y r South Yarmouth, MA 02664 5 (508) 398-2231 Ext. 1261 \ CONSTRUCTION ADDRESS: e w,.9 L'i c.y 4 L..ti,. ` it ) '- ASSESSOR'S INFORMATION: Map: Parcel: OWNER: C {J l< /ter `ri 3C T_5" 1 i 7 NAME :Mike McCarthy TEL. # CONTRACTOR: ,; PO Box 522��-�� n 1 NAME West Dennis, �A1�iDi1 rAgtL£SS TEL.# �'' Cell 4508) 280-6964 19�Residential mg8633 HIC-169393 Est.Cost of Construction S ) G`' 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 r-- *The debris will be disposed of at: .q- e.),,<<' 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 e prosecution under M.G.L.Ch.268,Section 1.Applicant's Signature: Date: Ic1.1s ii Owners Signature(or attachment) AA1L t L Date: Approved By: I-v Date: fe7'-G 7/7 Building Official esi EMAIL ADDRE 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 5 � 3L--7- ei7r? RISE --- s4, 6--" 2 _ ENGINEERING` OWNER AUTHORIZATION FORM I, Carol Taylor (Owner's Name) owner of the property located at: 25 Woodcrest 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. a Owner's Signature Date RISE Engineering, a Division of Thielsch Engineering, Inc. 5 Dupont Avenue I South Yarmouth, MA 02664 1508-568-1926 www.RISEengineering.com ,9:4 FO-,i2~-/Me}-eadi 0-/ teci-e/4- Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Individual MICHAEL MCCARTHY Registration: 169393 P.O.BOX Expiration: 06/15/2021 WEST DENNIS,MA 02670 Update Address and Return Card. SCA 1 0 20M-05/17 girl F.mrno r. i/. i' '. , i-.ie//i 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 e 06/15/2021 1000 Washington Street -Suite 710 MICHAEL MCCARTHY Boston,MA 02118' _ i MICHAEL F.MCCARTH 6 RANGLEY LN. �,�,a..rCc./��,•k f 11 SOUTH DENNIS,MA 02660 Undersecretary L Not validrwig'iout signature • FOfttltfGi • nyrealth of MassaEhus . !'"'� DivI,sioft of Rrtrf+eie�nal f:ib�.nsure Board of Buiidi McCarthyn9 f esWati and Standards Constr l M . :• r'viaor q► . Has enecialetdiy Carnaletedthe Nl o et CS.58633 Celliiieee dlilyafAtlg $t 11 �1.J M ,e''1 a wan PO BOX . i _iww as._ , . . .,,,,„,:„.,%,„ : . ObalarelitaNa w.i►raor'rs►�frasrt I4otrMttwNrrawbedsd •..m...�....d......,.... Commissioner - , ... .., ,... . .._. „ ,„.....„,„.: -...:,. . ....:...,..:. , .. , . :... ..... ,.. :.. . 00158712 .� . M U.S.tkena w,r of tabs ">Irw" X' 'rr s d end Health Administration t, Michael McCarthy oriapzipvcciroptosso:104100r TrairiMlp Qlilaeis fh ooRparW efW.y"iiif:Fhib - ',Wifely n - • a. s • The Commonwealth of Massachusetts - ice Department oflndustrialAccidents �` _Eelillo, 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 McCarthy . y Please Print Legibly Name{Business/Organization/Individual): aelMc Address: PO Box 52 City/State/Zip: one • Are you an employer?Check the appropriate box: Type of project('required): 1.Q I am a employer with (. employees(MI and/or part time).* 7. New construction 2.0 I am d Sole proprietor or 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. El Demolition 10 0 Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole I1.0 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.insuranee.t ❑ p 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.[�. ther �r)../ � • 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 providingworkers'compensation Insurance for my employees. Below is the policy and job site Information: • Insurance Company Name: Nk+1'c.n, Li c•1j;I.4./ + 'Pt'f t 1 c Policy#or Self-ins.Lie.#: I k/«‘1 Sly Expiration Date: P-ii• ►c)i q 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 e ns y' 'enalties of perjury that the information provided above is true and correct. Signature: Date: I 1 ) Phone#: (jt i ).tu-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.CityiTown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: