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EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261
•
CONSTRUCTION ADDRESS: 9 �%1 ve -"t{-e_ -17t'c f c L , .,,_1 t
ASSESSOR'S INFORMATION:
Map: I`j Parcel: ��
OWNER:
ti'f. c�.r� 5•�t_ 6 ) 3c a —I T6
NAME (Mike McCarthy Citriliglil!s TEL. #
PO Box 52
CONTRACTOR:
NAME West Dennis, MANR/§709DREss TEL.#
Cell (508) 280-6964
Residential CSE4 HIC-169393 Est. Cost of Construction$ /S'C "--
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 LZ--
Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing
*The debris will be disposed of at: -I- J x(`)
Location of Facility
I declare under penalties of perjury that h ta�teme herein 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 revoc ; oldt I Q and€or prosecution under M.G.L.Ch.268,Section 1.
•
Applicant's Signature: / Date: l 111 J It 1
Owners Signature(or attachment) , + L.. Date: l
Approved By: � L� v Dat/ -Pr
Building Offici or de ee) EMAIL AD S:
Zoning District:
Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes E No
Water Resource Protection District: Within 100 ft.of Wetlands:
0 Yes ❑ No 0 Yes No
DocuSign Envelope ID:B0E54D68-6450-448A-B473-E913B68F78C7 ' o 3(.2 t'ito I
RISE
ENGINEERING
Z saz $2 • 2i
OWNER AUTHORIZATION FORM
1, Mary Barry
(Owner's Name)
owner of the property located at:
9 Belvedere Terrace
(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.
r----DocuSigned by:
a
`�F7GR57/1hd7RSdFR
Owner's Signature
10/29/2019 I 10:28 AM EDT
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
14-011 't Department oflndustrialAccidents
:Yfl= a 1 Congress Street,Suite 100
_` = Boston,111A 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): naiad_McCh C :'
Gr. Y•vt vur•. �r1G.
Address: PO Box 52
Welt
City/State/Zip:
•
Are you an employer?Check the appropriate box: Type of project('required):
I.Q I am a employer with '.�- employees(full and/or part-time).* 7. ❑New construction
2.0 lam a sole proprietor of partnership and have no employees working for me in S. Remodeling
any capacity.[No workers'comp.insurance required.]. •
•
3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required]t 9• Demolition
4.❑I 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
proprietor with no employees. 12.0 Plumbing repairs or additions
5.0 I am•a general contractor and I have hired the sub-contractors listed on the attached sheet 13.0 Roof repairs
These sub-contractors have employees and have worker'comp.insurance.:
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.[ Iter 5►-.>. I
152,§1(4),and we have no employees.[No workers'comp.insurance required.] •
*Any applicant that checks box of 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 providing workers'compensation insurance for my employees. Below is the policy and job site
information..
Insurance Company Name: NS'�t•or�c I Li cj>;I i�/ k I"►d 1 •
Policy#or Self-ins.Lie.#: 1 1k/C-4-4 3 57/ Expiration Date: I',-)I f'17
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 • •enalties of perjury that the information provided above is true and correct
Signature: _ Date: 1 1 )rfl t F
Phone#, C',t) a-Ec,-G IC t>
Official use only. Do not write in this area,to be completed by city or town offfciaL
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#:
tr4 FO-/'12/920-/M08,C41.1 0-/ 4-
•
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.
CA 1 0 20M-05/17
-We Wevninewziea61JezdeAseiZi
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:
fildi iighti2B Expiration Office of Consumer Affairs and Business Regulation
18030 -.. 06/15/2021 1000 Washington Street -Suite 710
MICHAEL MCCOTIAt•,-- t.,."; Boston,MA 02118 / /------
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SOUTH DENNIS,MA-02660 ' :•;•Undersecretary Not valid4 out signature
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