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Home My WebLink AboutBld-20-004123 4- . O • -Permit# . - S _ Q 011+' _ `Amount %` urrw n C. d`°* E :Permit expires 180 days from a-D-0)N t)--LA + 2.3 W {issue date EXPRESS BUILDING PERMIT APPLICAT �C E I V E TOWN OF YARMOUTH a Yarmouth Building DepartmentNfj7F 1146 Route 28 - _ ..__:_. _ _ BUIL South Yarmouth, MA 02664 By a T _ (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: J f F h y)1., a ..l• ASSESSOR'S INFORMATION: y Map: Parcel: 1/ OWNER: � Iccn / ,xDs- 5�.., (s- ) 3,y_oi1f NAME Mike Mc �struction EL. # CONTRACTOR: PO Box 52 NAME West Detnnisiafts02670 TEL.# ff Cell (508) 280-6964 GYResidential ❑Commercic-SL-58633 HIC-16r9t393t of Construction$ Home Improvement Contractor Lie.# 1 G j 3') 3 Construction Supervisor Lie.# 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 V Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: S 1- EX C o J v„"f-k ! �<yynt. , Ii A Location of Facility i I declare under penalties of perjury that the stateme -h in c ntained 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 ' prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: I) ; I.)-- Owners Signature(or attachment) T k.,.,.1._ £ Date: I/) i--))�,-.)��- Approved By: Date: f i�0� Building Official(or design EMAIL ADDRESS- Zoning District: Historical District: 0 Yes E. No Flood Plain Zone: 0 Yes E No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 2 No xc; 35 y Permit Authorization mass save Form 1>(14 5°` ca) 12 /z- Yz :a tnox SMe.mi"+xn4-nr,Fr+:,..nt, Site ID: 3951379 Customer: Kathleen Gray Maseda &( ' ` .s.Q-AA ,owner of the property located at: (Owner's Name,printed) 55 Phyllis Drive South Yarmouth, MA 02664 (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. Owner's Signature'. �,��,� u, Date: \Z,\1 c ► 1 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 Rev.102015 • - The Commonwealth of Massachusetts _ _./ Department of Industrial Accidents • c .1 eY11-w" 1 Congress Street,Suite 100 . `:_E�e�_ • Boston,MA 02114-2017 • • yy 8ir...I,t+� www.massgov/dia Nirorlcers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. • TO BE FILED WITH THE PERM TT NG AUTHORITY. Applicant Information s Please Print Leeibly Name{Business/Organization/Individual): MkhIel1eC>l y. CGr.54-ire,a_•t1'v‘i>. r,C. Address: P0 Box 52 — -- City/State/Zip: -_-------------•-W F Dl AO2 —_ _-- -- ... one • Are you an employer?Check the appropriate box: Type of project('required): I.Q I em a employer with '� employees(fhll and/or part-time).* 7. 0 New construction 2.0 I am d sole proprietor of partnership end have no employees working for me in S. ❑Remodeling any capacity.[No workers'comp insurance required]. • 9. ❑Demolition . 3.0 I am a homeowner doing all work myself:[No workers'comp.insurance required.]t 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10❑Building addition • • ensure that all contractors ekher have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.❑Tama general contractor and I have hired the sub-contractors listed on the attached sheet These sub-contractors have employees and have workers'comp.insurance.* 13.❑LRoof repairs • 6.0We areacorporation and its officers have exercised their right14.[t�6ther it 1.I„.� of exemption perMOL c. 152.11(4),and we have no employees.[No workers'comp.insurance required.] . .*Any applicant that checks box it mist also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work end 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'amp policy number. I am an employer that is provtdingworkers'compensation insurance for my employees. Below is the policy andJob site information. Insurance Company Name: Nc41'c.n�I 1i c,/>;I i 4/ + "F. it -r . Policy#or Self-ins.Lic.#: % 5WC0 33 1_a11Expiration Date 1,- l)I a 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$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 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 cerllfy und. ,c%, /�, ,a ' ' of perjury that the information provided above is true and correct Signature: . Date: I -1 rflt f • • Phone#: (act) ,-to-G 14 cr Official use only. Do not iurlte in this area,to ke completed by city or town off ciaL 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#: . . , ,74 r ' 4 & eh..4., Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, Massachusetts 02118 Home Improvement-Contractor Registration • , , . .._ .....,.. _ Type: Individual -1 e: ,-..,-.. 7.,•:. , ' ,._ , .:s..:., -. Registration: 169393 MICHAEL MCCARTHY '':7.: '-'i' -- I .=I '0';' Expiration: 06/15/2021 P.O.BOX 52 WEST DENNIS,MA 02670 - - - , .. _ Update Address and Return Card. ... SCA 1 0 2014-05/17 • AS $90.02/1AAVet/690,Acy"../iga<AA2.01a.Aill3 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: allglitiBiBil ZERIBIU2S Office of Consumer Affairs and Business Regulation fpfilic : 06/15/2021 1000 Washington Street -Suite 710 MICHAEL MCCIWO.,::-..---'-:-----7--- -7.t;; Boston,MA 0211( „..- /.......------ , ' . l ./ . _ ___--,--_---sa.:0-:a-----..--; i / • t! MICHAEL F.MCCiNMkt---',7,-: j7 e/ U ,,-.-......_,-y:, ,/,..„,st a.gri.s.s• 6 RANGLEY LN. \-'1,;,:=„....-.—'SOUTH DENNIS,MA'02060 ' Undersecretary ii Not val out signature 4o7----;---!--------------„., ... .,oreencin....... ,%imamtp,s,....i._ ofiviiiiitacti,,.........usatts,.... . • ...... . . . . .. . _ . .,. . . michale mccalthr- , 4. ; • 1 COnstilupprvfoor Migkiteby CimillMollon : ; ,s- - .:- . 1 CS-45863S - : - . •:.i.• ''• -• ' Has suosepatOrtrimpistideveflaiticend Fair i :"' . '' -', - •,, ; , , . . Oillblees Thilidni Oveme . .. EridigliAufswit2011 . . ; ReettAitil , -.....': C.,..c , •• -• , . ' ‘.0°."-. . POIROX42 -..1; . ';i:ii,, .. . .;r: .of•''..# : .. "EST DENNIS* . : "• : #.. Is, # • 4 I I 1 I r• '.- . . : , . 1110.11111nuffiliir lawerwitilin - NATIONAL Nana ^ if -t, tistrillituommoiNessm/ - ' Cenirnbabarter . . -. _ . . - :qk..;!---.:,,,-"-::-::,.::::::,,,:- •-....:--.7--.. 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