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Home My WebLink AboutBld-20-003704 04,YAR Uttice Use Only L 1 �►�t O 1 Permit# O H !Amount ��*oero"«°"4 cad I Permit expires 180 days from ' u)— j.�,� 370 ;issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 CIC-4 39 QS South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: c(.1 ( -)-- ✓ /'/�mot l)--- ASSESSOR'S INFORMATION: Map: Parcel: OWNER: Cit-;n` ��w5t_ S—y),.._ 779 — Ci7`—L17d7 NAME Mike McCarthy Ctiliartket44K TEL. # CONTRACTOR: PO Box 52 NAME West Dennis, MI�uCh2 VAREss TEL.# Cell (508) 280-6964y Residential CSf' '-'iC-169393 Est.Cost of Construction$ �u- Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) G I am the homeowner G I am the sole proprietor '' 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: 5+r C x( Location of Facility I declare under penalties of perjury that the sta m is he in 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 . cense., or prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: A-, Date: i I,?),),:- Owners Signature(or attachment) A2*---L Date: Approved By: / Date: —20 Building 1 '_ or �—2 de ignee) E ADDRESS: Zoning District: Historical District: ❑ Yes G No Flood Plain Zone: G Yes G No Water Resource Protection District: Within 100 ft. of Wetlands: 0 Yes 0 No G Yes E No 40041rE Permit Authorization (\, 31,'-1S6` (2- 13 mass save Form Swamp,,through r%ergy of twncy Site ID: 3908097 Customer: Elaine Savage C i Q. e•N g_ ,owner of the property located at: (Owner's Name,printed) 5 56 Baxter Avenue West Yarmouth, MA 02673 (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: d3/44064..A— Date: 47:4%/ - / p? tf / 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 ra-nz €0.eai 4 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: 06/15P2021 P.O.BOX 52 WEST DENNIS,MA 02670 . ,. _ Update Address and Return Card. SCA 1 0 20M-05/17 .92:5 Few7,-.2evieueaegf,/ligaAsae,(6 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: findigaillil Expiration Office of Consumer Affairs and Business Regulation I6939..,- ,:: 06/15/2021 1000 Washington Street -Suite 710 MICHAEL MCCARTHY: - Boston,MA 02118.1 • / -- •- ,• : ' -'.,-_---,':' •.-_--i--- , ,' , /- _ -_,_.. ,j::-• —,--7_i; ,,--- .. /i MICHAEL F.MCCAArr-; : /2 0.//, i: st.,.,1 6 RANGLEY LN. .. • '-- ..•' ' " ,!04%.•otea.t,0/1.9.4' ..',. SOUTH DENNIS,MA Not valM4out signature.'"02660 r Undersecretary I et4 r:.."''7.'"'" '".'""" ." .'''''''''."..'"""""••••••...h.m.......iii.........kip 00hrOffinaniskon*raft Of MateaChlitatti •.- . Board of. PratessiOnal Licensure ..; . asthma woolly- % Building R ,, ons and Standards i Cons!, ' ; itgppryisor .. , Meallegiy Cosilmsation ' Has sualilsitiOptsOnvistideslistionsi Fair' ! CS,058633 - .:. ) Ctsitsloss llskilsa Moss ,L-T i° ;:- ,Iit ?- ,. , .. • N 2111daysfAmass*2011 . oma J , ,,,#.'... PO nom - ili WEST Min Am , ;';'- - 10%1 • • 00.10retftille NATIONAL MOOR , .11 I, ' Nee seMtiatlassembesaad • ......m1r.......obadmeymonoop COMMIllatOtter '104441" °..A 1."" .." I . I.F9Mtosisass...no... , • _ , ... . - •W'::'..7-'. ' -::: ' --:;•:-.'. •;;' *4 ,-. ...- s'.''''' ' . OSHA 0 0 1558712 : : cuilobaltiFtwonigiretcmatins, .r.: .-:us.Ospounent of Labor 3.4?...4 Occupalkmattitalety end Heath Admiesitatiots Michael McCarthy bap;SIWCOIN100.01:104104ar 410,*On6tgalMitilnitHeid-th TlngAbiliWi 42 M;,-. , - ... .. ._.: r - . ' ''.. ilsiblailliTh ieliailhoft - :14:. ' ":'..- .4' •-•":- 1‘,:•:: . ' -: :.109/0 •: ':.?' .....t...1,...'.1.1;:i • Po) • . . • .. . -... • The Commonwealth of Massachusetts • _- ��t/ • Department oflndustrialAccidents 1, 1 Congress Street,Suite 100 :_ e1e►.-?• Boston,MA 02114-2017 • — rr www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. • TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information ,�. iPlease Print Legibly Name{Business/Organization/Individual): Michael McCarthy CGr.S'1 r2�Tvu>, r�C. Address: P0 Box 52 - - City/State/Zip: - -------- none111s.Are you an employer?Check the appropriate box: Type of project('required): 1.13 lam a employer with '�- employees(MI 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. Remodeling any capacity.(No workers'comp.insurance required.). • • 3.0 I am a homeowner doing all work myself,[No workers'comp.insurance required)t 9. ❑Demolition 4.0I am a homeowner and will be hiringcontractors to conduct all work on my10 O Building addition 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,❑Plumbing repairs or additions S.a I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.0 Roof repairs These sub-contractors have employees and have workers'comp.insurance.: 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.[ tfier Z' 1./+. 152,§I(4),and we have no employees.[No workers'comp,insurance required.] • *Any applicant that checks box O1 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 en additional sheet showing the name of the sub-contractors and state whether or not those entities have • employees. lithe sub-contractors have employees,they must provide their workers'comp.policy number. lam an employer that is providing workers'compensation insurance for my employees. Below is the policy andJob site information. Insurance Company Name: V c.+t`o^....I Li cJ ;� •17 k f' ,rt —1.—,.,t- Policy#or Self-ins.Lic.#: V 1 k/C?'1' S7'/ Expiration Date: 1•a-)►C)i 9 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.by-a 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 es of perjury that the information provided above is true and correct Signature: Date: I)-/'CI I• F • Phone#: 'c.t) -(SG b Official use only. Do not ivrite in this area,to lie completed by city or town offi'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#: