The URL can be used to link to this page

Home My WebLink AboutBld-20-003149 .01:yAR ;Office Use Only ' g, O i Permit/ O . 1 /", y. {Amount -. S ��MA��TTAGM CS[ 1 �°�),�°'ramc.* E� _�,` �� {Permit expires 180 days from { zo Li e i issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH '`ill Yarmouth Building Department 1146 Route 28 if- sot/ South Yarmouth, MA 02664 " " (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: S O /vl(c,r 0-, [_3S4,, , ►'). 1>i)r ASSESSOR'S INFORMATION: Map: Parcel: OWNER: lj�rr\k,,: 1.3,r\OA .cc I ",- 1..1' ' kc l-C Si.i NAME Mike McCartllltElattstruction TEL. # CONTRACTOR: PO Box 52 NAME West DenniswALAAO2€ O TEL.# Cell (508) 280-6964 esidential ❑C Eci 8633 HIC-169393 Est. Cost of Construction$ /G w Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) 0 I am the homeowner ❑ I am the sole proprietor 14ave 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 Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: -c_5(co Location of Facility I declare under penalties of perjury that the stat ents 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 revocatilo f 1 n for s cution under M.G.L.Ch.268,Section 1. Applicant's Signature: 66// Date: 11 l-1 hi / Owners Signature(or attachment) A-.}- - L/.- Date: I/I1? //( Approved By: ,./„�,., Date: ,\' A)r Building Official(or designee) EMAIL ADDRESS: Zoning District: Historical District: 0 Yes E No Flood Plain Zone: D Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 7 No futLji y5 - 03 i‘,M3le/et Permit Authorization ��,�I ►oosa C) t2-"i2-y2 mass Salle Form � ,��' �2 Swings throughenergy ethoency, Site ID: 3798980 Customer: Bernard Langkafel I. �Q(d l a n kU {f 1 ,owner of the property located at: (Owner's Nar printed) 50 Nearmeadows Road West Yarmouth, MA 02673 (Property Street Address) (Crty) hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed below to act on my behalf and obtain a building permit to perform insulation and/or weatherization work on my property. Owner's Signature: if Date: g — 19 FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: Participating Contractor Date Name: RISE Engineering Phone: 401-784-3700 Email: Page 1 of 1 For Office Use Only Rev.102015 • • _ The Commonwealth of Massachusetts � Department of • ! '/ Industrial Accidents =i11_ 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 Please Print Legibly Name{Business/Organization/Individual): MichaelMcC rthy Address: PO Box 52 - - City/State/Zip: _ ------- West tll• nlel . 6�—Ar • e you an employer?Check the appropriate box: Type of project('required): 1.f I am a employer with �, employees(full and/orpart-time).* 7. New construction 2.01 am d sole proprietor or partnership and have no employees working forme in S. Eit Remodeling any capacity.[No workers'comp.insurance required.]. . 3.01 am a homeowner doing all work myself.[No workers'comp.insurance required]t 9. ❑Demolition 4.01 am a homeowner and will be hiringcontractors to conduct all work on myproperty. 10❑Building addition Iwill • • ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors 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 workers'comp.insurance.t 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.126ther 1..e% 152,§1(4),end 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 providing workers'compensation insurance for my employees. Below is the policy and fob site information: Insurance Company Name: `Nr.4-►r,.^,I Lick›;I iA-, + �►f. Tr S Policy#or Self-ins.Lic.#: V 1 Ic1/4/(.. '1 57`/ Expiration Date: 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 a Ins 'gnalties of perjury that the information provided above is true and correct Signature: Data: l 1-I'fi l F ' Phone#: (th) Au-4 IC b 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#: 4 Fay e>4'2,45 4- Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, Massachusetts 02118 Home ImprovementContractor Registration Type: Individual MICHAEL MCCARTHY Registration: 169393 Expiration: 06/15/2021 P.O.BOX 52 WEST DENNIS,MA 02670 _ Update Address and Return Card. SCA 1 0 20M-05/17 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: Reaistratioh Expiration Office of Consumer Affairs and Business Regulation 4. - 06/15/2021 1000 Washington Street -Suite 710 MICHAEL MCCARTHYBoston,MA 02118 , / - , � �r MICHAEL F.MCCAJ1 /� / �' f 6 RANGLEY LN. ofa igos �' l� SOUTH DENNIS,MA 0 Undersecretary Not valid-4 out signature i;oat of Maaohu> al Diirision Board of Building oaf:onsLind standards f l Constor and s andards tlta�. i R�lsr. CS 8633 $or , tddWrofA umt�011 L J - 4 fi • I A a (44.,..„...,...._ j s PIAII iN�L rli#R �AfFtj • ,,„„tulaa....... . ...•. . ... . ,_ , . _. . . , . ` ._._ ,... . .; : = -...„ s� ..ice 411 ......z.. .... 6... 00i5-58712 1" - ate ,LGC� j t us.Oeparbnrnt of tabor Optional y ohs Hpe Administration >: • 1--1 20ifiedik Michael McCarthy . i.. __.