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Home My WebLink AboutBld-20-003150 A,.O1,YAR`7 ;Office Use Only � t,�l O i Permit* 3�-� Y O . ,� . H (Amount tAz,c3 ,."°",`°"'cad !Permit expires 180 days from BL6-3 v"31J V .tissue Qate_ EXPRESS BUILDING PERMIT APPLICATION . TOWN OF YARMOUTH i 4r r,, Yarmouth Building Department 1146 Route 28 .C.e* igt:' j South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 3 7 &-t-NCY/..t..- Le,it • .-._rL ASSESSOR'S INFORMATION: Map: Parcel: OWNER: V-t_r Lci'c%.,,L 6-60 3`// L/17 NAME Mike Mcifttruction TEL. # CONTRACTOR: PO Box 52 NAME West Dtainithi~s02670 TEL.# esidential CommercialCell (508) 280-6964 SL-5863 1 -(--160. 'Cost of Construction$ j L' Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) I am the homeowner ❑ 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 1/4./ Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: .4- Cx.c‘. Location of Facility I declare under penalties of perjury that the stat ments 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 revocat of y ' rls and dosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: / Date: Ii k? I.4 Owners Signature(or attachme t) k t.l,. Date: 11 117/ I i Approved By: ��- Date: VI -1) ' l5 Building Official(or designee) EMAIL ADDRESS: Zoning District: Historical District: ❑ Yes = No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No a Yes ❑ No DocuSign Envelope ID:OEF9A2A2-62C0-4F1C-89A2-492DB0246D94 S o) 24( 1-I Z."49 c ��i - � -z sue' � �o �' �- 3 3 RISE sSte _ I (o s ENGINEERING' ' 2 l OWNER AUTHORIZATION FORM 1, Kenneth Leroux (Owner's Name) owner of the property located at: 37 Banister Lane (Property Address) Bass River, MA 02664 (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. DocuSignsd by: —6A62F9FCDO17405 Owner's Signature 11/6/2019 1 1:16 PM EST 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 • ly=�,1�i�y"/ Department of Industrial Accidents • =_=i11 1 Congress Street,Suite 100 Tip ; • Boston,MA 02114-2017 ,_ sr • „t• www.mass gov/ilia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. • TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please PrintLeEibly Name-(Business/Organization/fndividual): Michael McCarthy Address: P0 Box 52 - - --------------- WC3� nl— Mb.�-- -- -- City/State/Zip: one Are you an employer?Check the appropriate box: Type of project('required): 1.[3 I era a employer with employees(full and/or par-time).* 7. New construction 2.0 I am hi sole proprietor of partnership and have no employees working forme in 8. D Remodeling any capacity.[No workers'comp.insurance required.). • , • 3.0I 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.Q Plumbing repairs or additions 5.0 I am•a genera contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp.insurance.t 13.11Roof repairs • 6.0 We are a corporation and its officers have exercised their right of exemption per MOL c. 14.06tller Sr>✓1•4.y 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. tContractors 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: S'rt'onc I Li cJ; i 4/ k /Ft-it T"S Policy#or Self-ins.Lic.#: 1 k/C3-4 3 57 y Expiration Date: I' -)ICI 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 punishable bye 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$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. , I do hereby certify and e ns�y s mates of perjury that the information provided above is true and correct Signature: Data: I)-I Id t l: • Phone#: (t.t} ?-feu- f C Official use only. Do not ivrite in this area,to be completed by city or town offlcie • City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: K70� � A Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, Massachusetts 02118 Home Improvement'Contractor Registration Type: Individual Registration: 169393 MICHAEL MCCARTHY P.O.BOX 52 Expiration: 06/15/2021 WEST DENNIS,MA 02670 Update Address and Return Card. SCA 1 0 20M-05/17 /e Ftwzinaaur t‘c/../14aAltz/re�sel s Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Individual before the expiration date. B found return to: Expiration Office of Consumer Affairs and Business Regulation 4 - 06/15/2021 1000 Washington Street -Suite 710 MICHAEL MCCARTHY Boston,MA 0211$' .�',.. �i MICHAEL F.MCCAR- /� /'/ i7 1 f I / 6 RANGLEY LN 'a j SOUTH DENNIS,MA 0 Not valid-4 out signature Undersecretary I. �... .,. Common. meth of assach4$� I Q • t Lit;a Board of SuNina ens and Stat►dards Constr Mfrs flarmiNfOOY COmPlailitifelationsi Mir. CS458633 _ v Olken.Vaining Course : °ayOlA 2O11 C �:y� }j{ • . . :...--- ., won orwmrstA , ' "- '4 , . , t ,flibadl�r 7'; i.4a` S NATIONAL megR d NetrewfelMessimbeesse .w.we..rrb--'--wep ' • osito 1558712 • ;.. ,,_ .1irtiribiailltillteipioit4ifwvas011aser ".-'' ' ' .'.. U.S.tlsperinsnt of Labor c:•„ s Oscup_tionaHlalsty end Mean ti 1 �;, ; Michael McCarthy Tw611npQtl ls�It#tr . -z,. val ' a a ot '' 1 t .. _ - r. . -