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ffco�Ord Permit expires 180 days from
AUG 2`19 :issue date
I EPPAAR PAR-TM—E.
EXPRESS I " ! .=- _ IT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS: 3 C--z 1 I PL
ASSESSOR'S INFORMATION:
Map: Parcel:
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OWNER: ��cr-�c -rc ,,.` I IW! 5 i h 77( 2 Y P,
NANI1 Like McCarthy c0nsitrallfrAliAli5RESs TEL. #
PO Box 52
CONTRACTOR: West Dennis, MA 02670
NAMEING ADDRESS TEL.#
Cell (508) 280-6
❑Residential CSL rcialHIC-169393 Est.Cost of Construction$ j lS
Home Improvement Contractor Lic.# Construction Supervisor Lic.#
Workman's Compensation Insurance: (check one)
0 I am the homeowner 0 I am the sole proprietor fYI 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 C�
Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing
*The debris will be disposed of at: I )cGo
Location of Facility
I declare under penalties of perjury that the statements rei 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 revocation of my lice fqi prose ion under M.G.L.Ch.268,Section 1.
Applicant's Signature: Date: [ I\ I 1
Owners Signature(or attachmen , — `• Date:
Approved By: Date:
Building fficial(or designee) 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 ❑ No
7L/ Z -g29I,
RISE
ENGINEERING"
OWNER AUTHORIZATION FORM
1, Katherine Peregrim
(Owner's Name)
owner of the property located at:
38 Lily Pond Drive
(Property Address)
South Yarmouth, 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.
P •
Owner's Signature
6- 19
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 02118
, ,
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
..Ze"e g~nerizocagife/.../ZaWada-Je/k
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 c Expiration Office of Consumer Affairs and Business Regulation
160303.::- ..- 06/15/2021 1000 Washington Street -Suite 710
MICHAEL MCCARTHY ---;-:---,",' Boston,MA 0211134 • i --
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MICHAEL F.F.MCCARtilY-77 ; /2 P:-//. // law /
6 RANGLEY LN. • ' -- ', Si.0m4-0114 1,0./.4. '
•,.. Not val "ittiout signature
SOUTH DENNIS,MA-02660 Undersecretary i
tiCirlmonwealth of MaSsachutetts
:. . Michael McCiathy
Board
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• _. The Commonwealth of Massachusetts
Pt!=�'—�'I Department of Industrial Accidents
r • 1 Congress Street,Suite 100
"• Boston,MA 02114-2017
• �, ,,sr www mass gov/dia
1.1
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
• TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information 1� Please
LPrint Legibly
Name{Business/Organization/Individual): Michael McCarthy
Address: PO Box 52
- - City/State/Zip: - ------- West ono 670-- --
•
•
Are you an employer?Check the appropriate box: Type of project('required):
1.Q 1 am a employer with S. employees(full and/or part-time).* 7. New construction
2.0 I am a sole proprietor of partnership and have no employees working for me in 8. 0 Remodeling
any capacity.[No workers'comp.insurance required.]. •
•
3.D I am a homeowner doing all work myself.[No workers'comp.insurance required.]: 9. CI Demolition
4.01 am a homeowner and will be hiringcontractors to conduct all work on myproperty. 10 Building addition
I will
• • ensure that all contractors either have workers'compensation insurance or are sole 1 1.0 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 13.0Roof repairs
These sub-contractors have employees and have workers'comp.insurance.t
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.(► then Sri
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 the name of the sub-contractors and state whether or not those entities have
employees. If the subcontractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providingworkers'compensation insurance for my employees. Below is the policy and fob site
information.
Insurance Company Name: Jc 4t'c.n..) L s/,,;1;47 4 /F►/t rr,c
•
Policy#or Self-ins.Lic.#: V 1 19../C-3`I 3 S• '/ Expiration Date: 1',-)►r/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 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 j' 'mollies of perjury that the information provided above is true and correct
Signature: Date: I ..) -J►F
Phone#: �St,t) aju-6 SC b
Official use only. Do not write in this area,to lie 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#: