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EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH ``" ` '` '
Yarmouth Building Department
1146 Route 28 CO .5,q '
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261
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CONSTRUCTION ADDRESS: W 1✓c.:(be" c k ie.)-
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ASSESSOR'S INFORMATION:
Map: Parcel:
OWNER: C k Stwo 5.&Not 5 .►� 77Y 2C� 3y�
NAME Mike McCarithyEleAl action TEL. #
CONTRACTOR: PO Box 52
NAME West DennwadAmalfi70 TEL.#
Cell (508) 280-6964
esidential 0 Conn 1 58633 IIIC-16939§t. Cost of Construction$ )sue-'
ni -
Home Improvement Contractor Lic.# Construction Supervisor Lic.#
Workman's Compensation Insurance: (check one) /
0 I am the homeowner ❑ I am the sole proprietor UPI 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*
q ( ) (max.2 layers) Insulation
Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing
*The debris will be disposed of at: S t T 'e X c a
Location of Facility
I declare under penalties of perjury that the statem nts herein co tamed 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 revocation of m cl, prosecution under M.G.L.Ch.268,Section 1.
Applicant's Signature: Date: I I I Y7 II C
Owners Signature(or attachment) k „y, Date: )1 1-')/ 11
Approved By: ✓ G� - Date: 11 ' :)-15
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 0 Yes C No
7 -7i 246 13Y8
R I SEc _ S6‘ 1(0) ref j -1
ENGINEERING
OWNER AUTHORIZATION FORM
I, Claudio Simoes
(Owner's Name)
owner of the property located at:
88 Barnacle Road
(Property Address)
Yarmouthport, 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.
Owner's Signature
Date ( ) 11
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
• ►A_ ft Department of IndustrialAccidents
• _i:N1I= 1 Congress Street,Suite 100
Boston,MA 02114-2017
'.,•sr 1 r www mass gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
• TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): MiCh$el McCarthy
Address: PO Box 52
- - - -- ---- West tni-lVit�02b"1�_ ----_----- --
City/State/Zip: one
Are you an employer?Check the appropriate box: Type of project(required):
1.Q 1 am a employer with '. employees(full and/or part-time).' 7. ❑New construction
2. I am d sole proprietor of partnershipand have no employees 8. Remodeling
p oyees working forme in
any capacity.[No workers'comp.insurance required.). •
9. CI Demolition .
3.0I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
4.0 I 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.❑Electrical repairs or additions
proprietors with no employees.
12.Q 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 workers'comp.insurance.:
• 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.�tfler �'►� .i I+
152,11(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 tie 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 fob site
information:
Insurance Company Name: /Vc.+ c.n� N/ ♦ "Fi rc. -r'
Policy#or Self-ins.Lic.#: LI C3-1 3 S3 y Expiration Date: P-)►f'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 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 a dins ' 'gnalties ofperfury that the information provided above is true and correct
Signature: Date: I�-I'fi'I
• Phone#: aF-o--CSC('
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#:
ra-,12,120-
9/
Office of 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.
SCA 1 Cr 20M-05/17
.9ire Wev,2,92evaaieez,a,6/..1ga,sdac/ukte,ai
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:
EtEdiglidiga Expiration Office of Consumer Affairs and Business Regulation
18939 ,--_-; 06/15/2021 1000 Washington Street -Suite 710
MICHAEL MCCAItTtpt-- _:--:-,t-.. . Boston,MA 021:18 ' /,------
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SOUTH DENNIS,MAiveso r :, Not val out signature
Undersecretary ii
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