HomeMy WebLinkAboutBld-20-004120 <?'• 'O `Permit#
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EXPRESS BUILDING PERMIT APPLICATIO -- - -1 j
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TOWN OF YARMOUTH
%Yarmouth Building Department JAN �� ��
1146 Route 28 Bl)! P EN
South Yarmouth, MA 02664 By
(508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS: y 1 Pap,s r.),-. Of- Y 12)‘-Y/-
ASSESSOR'S INFORMATION:
Map: Parcel:
OWNER: S(-,,11, 5.,,-v,L (5-t) 7C-19 I a
NAME Mike Mcustruction TEL. #
CONTRACTOR: PO Box 52
NAME West laginxismMAs02670 TEL.#
Cell (508) 280-6964
residential 0 Commerci SL-58633 IIIC-1641343t of Construction$
Home Improvement Contractor Lic.# 1 b�>)'3 Construction Supervisor Lic.# 5 V (,5
Workman's Compensation Insurance: (check one)
0 I am the homeowner 0 I am the sole proprietor 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 ✓
Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing
*The debris will be disposed of at: S 1— EXCL.) fr), J t - - )1 A
Location of Facility
I declare under penalties of perjury that the statemen her ' cont ' d 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 " for secution under M.G.L.Ch.268,Section 1.
Applicant's Signature: ,/ Date: 11 :/).
Owners Signature(or attachment) -14-\,.L< . Date: I .0 5-1.).-.1--
Approved .r,
Approved By: *-0 Date: /—2c Gc,
Building Official(or desi ee) EMAIL ADDRESS': !J�
Zoning District:
Historical District: 0 Yes ❑ No Flood Plain Zone: 0 Yes 0 No
Water Resource Protection District: Within 100 ft.of Wetlands:
0 Yes 0 No 0 Yes 2 No
c $ ? 7(, y2I2
RISE
ENGINEERING
OWNER AUTHORIZATION FORM
1, Edward Smith
(Owner's Name)
owner of the property located at:
44 Helmsman Drive
(Property Address)
Yarmouthport, MA 02675
(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.
Owner's Signature
Cr
1� u
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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. The Commonwealth of Massachusetts
l".:--.•-..- -- i— Department oflndustrialAccidents
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c =?rn.= a 1 Congress Street,Suite 100 .
`:=11P= ''• Boston,MA 02114-2017
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+` www.mass gav/die
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
•
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Leeibly
Name{Business/Organization/Individual): McCarthy. `C.a.I,h,:,e_•}-vcir. :1;--IC.
Address: PO Boa 52
- -- City/State/Zip: ----- . -------WCS� i ii O2 _ --- -
ne
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Are you an employer?Check the appropriate box: Type of project('required):
1.Q I am a employer with employees(}Mil and/or pert-time).* 7. ❑New construction
2.0 Ian'r sole proprietor of pa lmship and have no employees working for me in 8. 0 Remodeling
any capacity.(No workers'comp.insurance required.]. 9. ❑Demolition• ,
3.01 am a homeowner doing all work myself[No workers'comp.insurance required.]t
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 11.0 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.
These sub-contractors !nuance.,have employees and have workers'comp.innce., 13.0 Roof repasts
• 6.0 We are a corporation and its officers have exercised their right of exemption per MIX e. 14.1 er S►•”j0"
152.11(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 sub-contractors 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. 1 �•
Insurance Company Name: Nc..41'4.,,�� L 1 i c,6,I i 7 4- ,I^i It - r c• .
Policy#or Self-ins.Lie.#: ti V'i WC-ci.1'. . 1-A Expiration Date 11)1 i,as
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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 a.152,§25A is a criminal violation punishable.bya fine up to 81,500.00
and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 8250.00 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 of perjury that the information provided above is true and correct
Signature: Date: I)-I r..t i
• • Phone#• @,k) ,-CSC*c
Official use only. Do not write in this area,to be completed by city or town ofj7ciaL •
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#:
,.. . ..
6>z.Office of of Consumer Affairs and Business Regulation
1000 Washington Street- Suite 710
Boston, Massachusetts 02118
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Home ImprovemeAtContractor Registration
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- •• _ ,_ , Type: Individual
•1 - -• % ' ----7- '-, egistration: 16939:3
MICHAEL MCCARTHY R Expiration: 06/15/2021
WEST DENNIS,MA 02670
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Update Address and Return Card.
SCA 1 0 20M-05/17
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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:
filiddkilaal Z2Wialgall Office of Consumer Affairs and Business Regulation
tVIStc.. --.7..11:1 06/15/2021 1000 Washington Street -Suite 710
MICHAEL MCOMITE*:: ;f:', Boston,MA 021141 , „:".„.......„...--
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SOUTH DENNIS,MA112666 r Undersecretary ti Not val out signature
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