HomeMy WebLinkAboutOwner Authorization Form ‘ , .
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RISE
ENGINEERING"
OWNER AUTHORIZATION FORM
1, EDWARD J PATRIZZI
(Owner's Name)
owner of the property located at:
40 Aft Road
(Property Address)
Bass River, MA 02664
(Property Address)
hereby authorize Cape Save Inc.
(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.
Cprt)—
Owner's Signature
-
Date
RISE Engineering, a Division of Thielsch Engineering, Inc.
5 Dupont Avenue I South Yarmouth, MA 02664 ( 508-568-1926
www.RlSEengineering.com
.01. s Use Only
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rl Permit expires 180 days from
•+ issue date
EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS: 40 Aft Road
ASSESSOR'S INFORMATION:
Map: 26 Parcel:49
OWNER: Edward Patrizzi same 860-690-3790
NAME PRESENT ADDRESS TEL. #
CONTRACTOR:William McCluskey/Cape Save 7-D Huntington Ave, S. Yarmouth 508-398-0398
NAME MAILING ADDRESS TEL.*/
1 Residential 0 Commercial Est.Cost of Construction$ 5000
Home Improvement Contractor Lic.# 171380 Construction Supervisor Lic.# IC 102776
Workman's Compensation Insurance: (check one)
0 I am the homeowner D I am the sole proprietor ■ I have Worker's Compensation Insurance
Insurance Company Name: Employers Mutual Casualty Company Worker's Comp.Policy# 5D77852
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 X
Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing
'The debris will be disposed of at: Yarmouth
Location of Facility
I declare under penalties of perjury that the statements 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 r re cation of my license and for prosecution under M.G.L.Ch.268,Section 1.
Applicant's Signature: Date: 10/14/19
Owners Signature(or attachmen attached Date:
Approved By: �� Date: /6' ///'
Buildin lc' or designee) EMAIL RESS:
Zoning District:
Historical District: Yes C No Flood Plain Zone: D. Yes D No RECEIVE I)
Water Resource Protection District: Within 100 ft.of Wetlands:
Yes ❑ No J Yes ❑ No OCT 15 2019
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by
BUILDING DcI-ANTiVENT i