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Home My WebLink AboutBld-20-000928 Office Use Only k -- - O O 'I . H t R C f D Amount V S' L/ I %-.? 4x' -- °`°*""' End''% -, y� `Permit expires 180 days from = • AUG 19 2019 issue date • DEPARTMENT EXPRESS BUIL 1 ► _ !-= --- 'PLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 /� (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: �7 -(�i^'1�( y ASSESSOR'S INFORMATION: ` Map: 3( Parcel: /v y OWNER: 1...-c,4") 1-4 IN ., S....r.(.... <t) ?IL l!— 77G NAME Mike McCarthy ConSiEss TEL. # CONTRACTOR: PO Box 52 NAME West Dennis, MA 1d it79ADDRBss TEL.# Cell (508) 280-6964 ❑Residential CSU58 ial HIC-169393 Est.Cost of Construction$ ] GC c- -- Home Improvement Contractor Lic.# Construction Supervisor Lie.# Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor 15'I 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 V Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: 5f ( Location of Facility I declare under penalties of perjury that the to nts her in 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 revocatio m ice a for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: / - Date: V f l f 1+ Owners Signature(or attachment) ' kic..c. Date: 1:5( Approved By: Date: 6 ' B ' cial or designee) EMAIL ADDRESS: Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No DocuSign Envelope ID:3D671 B6F-BDBC-449E-BD1 E-3CCFF68AD941 ,51g °'t -1'-4-O 4111M Permit Authorization mass save Form ��,s Sarongst�rotoph ciherigy etbei ency V Site ID: 3859209 Customer: Lori Lewis Lori Lewis I, ,owner of the property located at: (Owner's Name,printed) 27 Camelot Road Yarmouth Port, MA 02675 (Property Street Address) (City) 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. —DocuSigned by: Owner's Signature: tAri. (kuit'S `—55AA96C DF 188449... Date: 8/5/2019 16:50 AM EDT 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 , Kam",/,? 010),� /4 . R Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Individual MCCARTHY Registration: 169393 MICHAEL P.O.BOX Expiration: 06/15/2021 WEST DENNIS,MA 02670 Update Address and Return Card. SCA 1 Ca 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: Registration Expiration Office of Consumer Affairs and Business Regulation 169 06/15/2021 1000 Washington Street -Suite 710 MICHAEL MCCARhY Boston,MA 0211$' /r,,.' .•/1:/ / .� MICHAEL F.MCCAM4 s � • Z; // 6 RANGLEY LN. idr•�...(a./a f1. SOUTH DENNIS,MA-02660 Undersecretary ; Not valid-Without lout signature alianwaaitft of Messachusetfs '`�` Otvision off Ft�sianai l:ke Bette• Michael McCarthy Board of Building a WaNfuts and Standards: on Oon ...., i Nos sum sirs atio al Flpn' CS.-0586 3 ,, r E. Oss trite ice. f �> ' t ' Q! er ' '' ddtvOfAugust 2011 . Mama j , PO Bests L '° , �, ENI q �� . d MIK ' ' `v � is..§a`.' ObOMI INPOa NATIONAL PIRa1R ' a Not aeitirerdeesen0eesed . ' wc................... + Lcrit141a!aa...... • r.. q( U.S.ikpertment of laborcgoTh , s Sa are!Heath Administration ,. •, Michael McCarthy has i+a4Ut,C mpl�tl a:1P110w 0ectipstanaISalsty and Neagh e n Training Coutas it1' Af1n0 $ • • The Commonwealth of Massachusetts k� � - 1=C/ Department of Industrial Accidents EY11= 1 Congress Street,Suite 100 _1_`- �7 • Boston,MA 02114-2017 • • ,.21�,0•� www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. • TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please PrintLegibly Name{Business/Organization/Individual): Michael McCarthy `c ,5+-v..�+'vc+r-, c. Address: PO Box 52 - - City/State/Zip: - ------- WC3t nig b�one —Ar • e you an employer?Cheek the appropriate box: Type of project(required): 1.Q I am a employer with employees(full and/or part-time).* 7. New construction 2411 am a sole proprietor or 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 workers'comp.insurance required.)t 9. ❑Demolition 10 0 Building addition 4.01 am a homeowner and will be hiring contractors to conduct all work on my property. I will • - 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 13.1p 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.[ thee ),./��I+ 152,§1(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 die 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: Vc +1,.", Li cJ;I i 4y 4- r 1'rc. Tn c Policy#or Self-ins.Lie.#: V 1 V(.3-1 3 571. Expiration Date: i'?-)►S/17j 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 t e ns enalties of perjury that the information provided above is true and correct Sienature: Data: I /sr)i F • Phone#: ( ,t' 'A-0-6 I C ti Official use only. Do not write 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 Cleric 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: