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Home My WebLink Aboutbld-20-004277 30Y.AR li Permit# O11 . H 'Amount S 'IATTA n C3 h. Permit expires 180 days from -. l issue date BU --ZV'4L77 IE G E N E ® EXPRESS BUILDING PERMIT APPLICATI TOWN OF YARMOUTH FEB () '3 2021 Yarmouth Building Department — 1146 Route 28 eyl 'l "'arN . South Yarmouth,MA 02664 /G (508) 398-2231 Ext. 1261 I CONSTRUCTION ADDRESS: L 1NiI 6 s y 17 }. 1 w�) ASSESSOR'S FORMATION: Map: Parcel: OWN. ��,� / '"ram fi 77��-4117-IiCt-i NAME Mike Mcialiallipeoustruction TEL. # CONTRACTOR: PO Box 52 NAME West DenitiluiViztts02670 TEL.# �Residential ❑Commerc'' Cell (508) 280-6964 eSL-58633 HIC-16 of Construction$ Home Improvement Contractor Lie.# 1 () ) 3 Construction Supervisor Lie.# 5 ( (, Workman's Compensation Insurance: (check one) 0 I am the homeowner ❑ 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 I/ Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: ÷ EX C 0 $ \ "1 J-.�c�-1r1�y I/A Location of Facility I declare under penalties of perjury that the stat ents 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 or revocation li and for prosecution under M.G.L.Ch.268,Section 1. )) Applicant's Signature: Date: l'- Owners Signature attachment) k r. AL Date: II)r i Approved By: ✓,�.� Date: . .40 Building Official(or designee) EMAIL 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 ❑ Yes 2 No RISCt C (I( - C54 CA' "7.-" -Li ti ENGINEERING" OWNER AUTHORIZATION FORM 1, Chris Morton (Owner's Name) owner of the property located at: 248 Camp Street (Property Address) West Yarmouth, MA 02673 (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. 1 V�-- Owner's Si nature Date RISE Engineering, a Division of Thielsch Engineering, Inc. 5 Dupont Avenue I South Yarmouth, MA 02664 1508-568-1926 www.RlSEengineering.com . - r4 g -/2 2,12 0 ellee7/ Office Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, Massachusetts 02118 , . Home Improvement Contractor Registration , ...z -- _ Type: Individual- - -•--...z.:1- .,-..,iq ,-. '' " '--:- -.--- •• --- • , ,•MICHAEL MCCARTHY Registration: 169393 '' ''- ' ). '''- ' '-'' ' Expinstion: owl 5r2cei P.O.BOX 52 WEST DENNIS,MA 02670 ,... . . . . .. Update Address and Return Card. SCA 1 0 20M-05/17 .94 reVrielaesaafeddif/../igcrAitzda.Afai 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: filicliklait Expiration Office of Consumer Affairs and Business Regulation 6989..,, ,-.4_06/15/2021 1000 Washington Street -Suite 710 Boston,MA B21181 , I "-...--' MICHAEL MCCWITgki:"; Y:, •-'15:27z-7,'z ..:1,Wr71,,-:2, , / . ,/ : t / MICHAEL F.MCOsINT,:' (/ / / 6 RANGLEY LN. .. ;,...7,7.,„,...,.._ '. •./. Not valIdA4 out signature SOUTH DENNIS,MA.:026;SGI ' Undersecretary t • * OwirkInwasith of lvfassichwafts preislener Pr?tesstitnali Licenser. Baa rd of Building, . ionctutai viccathr .4 anti kaitdarda • ' I Consk, : tileppvisor '. Mitineaker Dosominealkia ., I CS,058634 . :i Has smossisita(rOmpistitiths-Nonal Fair• . )., , : ) Cillisse Twining Oslo* ;.-; _ '.,-ve , s'.,. .. . .t. . MICHAEL J ' ,..,•• '4 4 ,:: 7.... 23"day OfIwwit2011 . .4•°.': Pe Ram tt.., - -4i., . • ..= II' - ,/ - WEST DENNIS* "1•1111. 1111111•11.• top%NillentIther •" . . .., if:m....4:1...0• 1 : : SlImmareMMNs SIAZIONAL FMB* . : 4 led mattruirmisMassil ' Cernaltilliefeer a. AL- - , . YMIkeillleowesria.... - • • - •• • • - „.. 1.•:::(1.:;'.7:. --.-er.. -, --.....;-•?::',. ---. -ij, , : •...- ' -..::' ' -:. .- OSHA -0 0 155 87-12 . . - ,-., - Aiiiii.i•iiiiftifiiicii ,--- - - .. . ,..- ,. .: . *ffirbsobsio"„e . '-'•:'-' '- ."-:;:‘• : ,•• 4,11001• Calitirwa. :•-1 U.B.Depagnent of Labor .1'4..,4'. ,. , hued Ilsolitodenialstratiort .:-.. ...:: -It /004.iitOreattittp . 4:: ;:-..: • Michael McCarthy umccoowgro.o,(toisw,F ,*.omiotoitffiriiith Urns .i,,e P....'.n.. • 1 . .. .. , .2' #' * 1. , r '• Y. - .. ..,,,‘-e, N 94,164.00,0114.101 : fR I. • " ' ' '..4 . '-:.919/07. "-?: '...'. ...4... ,,....„, !‘i.t.'• .1. .. . I . - . ± • . - • , • - The Commonwealth of Massachusetts • ='/ Department of Industrial Accidents 7411= 3 1 Congress Street,Suite 100 _E�a= • Boston,MA 02114 2017 • www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. . • TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Leeibly Name(Business/Organization/Individual): Y .. Address: PO Box 52 - -- City/State/Zip: ------- WC3t oneRlb�_ _ ----- -- Are you an employer?Check the appropriate box: . Type of project(required): 1.Q I am a employer with employees(fidl and/or part-time).* 7. ❑New construction 2.0 I am d sole proprietor of putnaship and have no employees working for me in 8. Remodeling any capacity.[No workersi comp.insurance required.]• 3. I am a homeowner doingall work m 1• 9. ❑Demolition D y:ci [No workers'comp.insurance required]+ 4. I am a homeowner and will be 10�Building addition hiring contractors to conduct all work on my properly. I will • • ensure that all contractors ether have worker compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no anployees. 12.0 Plumbing repairs or additions 5.0 I am.a general contractor and I have blind the sub-contractors listed on the attached sheet. 13.0ROOf repairs These sub-contractors have employees and have workers'croup.insurance.= • 6.0 We are a corporation and w officers have exercised their right of exemption per MOL a 14.[�tlter Sr 3,/!.i, 152,§1(4),and we have no employees.[No workers'comp.insurance required.] . *Any applicant that checks box 01 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 mnew 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. Insurance Company Name: N�'�t'c.n.t Li c,b,)i 47 + "1"—"c• WC 3 1 ' Policy#or Self-ins.Lic.#: y V cj � 3 .a� Expiration Date:_ 11�i))aLI • 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.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$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 teal*and e' ,. , - ' of perJury that the information provided above is true and correct Signature: f / Date: I:.-I'di ' • Phone#' (r t) ?to.6I C y Official use only. Do not iprite in this area,to he 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 Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: