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1Permit expires 180 days from
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EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28 CV,41----31 %
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South Yarmouth, MA 02664 5
(508) 398-2231 Ext. 1261 p
CONSTRUCTION ADDRESS: ,,.�1 �� , F1- •
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ASSESSOR'S INFORMATION:
Map: Parcel:
OWNER: 14.cL..y (•)h�-C S,,n,4_ (;i'l_ C/ .7— 9 z NAME Mike McCarthy of f NIEss TEL. #
CONTRACTOR: PO Box 52
NAMEWest Dennis, MA OZ DRESS TEL.#
Cell (508) 280-6964
0 Residential Cs14-133)8403a1 HIC-169393 Est.Cost of Construction$ ' (j c`_
Home Improvement Contractor Lic.# Construction Supervisor Lic.#
Workman's Compensation Insurance: (check one)
0 I am the homeowner ❑ I am the sole proprietorave 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 ✓
Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing
*The debris will be disposed of at: 54 J e-X,O
Location of Facility
I declare under penalties of perjury that the tat en 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 revocati of y I e and for prosecution under M.G.L.Ch.268,Section 1.
Applicant's Signature: Date: )
Owners Signature(or attachment) ,A k Vt•.L- Date:
Approved By: 4/ .�iv1Ai Date: /G "/7
Building 0 al esinee) L ADDRESS:
Zoning District:
Historical District: ❑ Yes ❑ No Flood Plain Zone: a Yes D No
Water Resource Protection District: Within 100 ft.of Wetlands:
0 Yes 0 No 0 Yes = No
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RISE "Sc'
ENGINEERING' �2-
OWNER AUTHORIZATION FORM
1, Richard Bishop
(Owner's Name)
owner of the property located at:
17 Point of Rocks Road
(Property Address)
Yarmouthport, MA 02675
(Property Address)
1i
hereby authorize ' F
(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.
11WL'I.d4
Owner's Signature
) l a
Date
RISE Engineering, a Division of Thielsch Engineering, Inc.
5 Dupont Avenue I South Yarmouth, MA 02664 1508-568-1926
www.RlSEengineering.com
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Office of Consumer Affairs and Business Regulation
1000 Washington Street - Suite 710
Boston, Massachusetts 021 18
Home Improvement Contractor Registration
-- Type: Individual
Registration: 169393
MICHAEL MCCARTHY Expiration: 06/15/2021
WEST DENNIS,MA 02670 ..
_ Update Address and Return Card.
SCA 1 0 20M-05/17
.:-.R; . .eit/dgezAiezuf,,Ase/h
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:
EiggikkAgit Expiration Office of Consumer Affairs and Business Regulation
41i9a9 ,..-,.., 06/15/2021 1000 Washington Street -Suite 710
Boston,MA.02118f ' /.....- ---
MICHAEL MCCARTHYI::-..--.. .,,''
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MICHAEL F.MCCAFWtVC----: •
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6 RANGLEY LN. ,-• ----. - • ditos4 •i
..; Not val out signature
SOUTH DENNIS,MA02660 , Undersecretary 4
n of Professional Lk
, • reilleittaid&tardy" Beard of swot:az:a ensure
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•
• The Commonwealth of Massachusetts
• u r-!! Department oflndustrialAccidents
' —1741�- 1 Congress Street,Suite 100
_1r:7= • 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): Michael McCarthy.
Address: PO Box 52
City/State/Zip: WeM D i0 l b�— —-- --- --
one
•
Are you an employer?Cheek the appropriate box: Type of project(required):
1.01 am a employer with ' . employees(full and/or part-time).* 7. ❑New construction
2.1:1 I am a sole proprietor of partnership and have no employees working for me in 8. Remodeling
any capacity.[No workers'comp.insurance required.]. .
•
3.0I am a homeowner doing all work myself.[No worker'comp.insurance required]t
9. 0 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.Q Electrical repairs or additions
proprietors with no employees. 12.0 Plumbing repairs or additions
5.0 I am 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.insurance.t
• 6.Q We are a corporation and its officers have exercised their right of exemption per MGL a14.126ther
152,11(4),and we have no employees.[No workers'comp.insurance required.] .
'Any applicant that checks box O1 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-conracton have employees,they must provide their workers'comp.policy number.
I am an employer that Is provldingworkers'compensation insurance for my employees. Below is the policy and fob site
information:
Insurance Company Name: Aic..'r t'on...1 Li cJi i 4/ + i"►Wit. -r S•
Policy#or Self-ins.Lic.#: Expiration Date: 1'?-)1 S'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 certlfy and e j 'enalties of perjury that the information provided above is true and correct:
Signature: Date: )Is4 s F
Phone#: @.•0ao-C1C9
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#: