Loading...
HomeMy WebLinkAboutBld-20-003705 :)Ottice Use Only •YAR '"$"' 's,. 0 I Permit# O - 1 'h - y Amount Permit expires 180 days from j issue date .l)av—33-7c EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 0.�11_ South Yarmouth, MA 02664 C•� (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: )> C + 7wL ASSESSOR'S INFORMATION: / Map: Parcel: ` OWNER: V.r';. lrf��� �i-.L 35(1-C�7S NXME Mike McCarthy Co;>o3>> 4, mSS TEL. # CONTRACTOR: PO Box 52 NAME West Dennis, M4ItTiL'fN1,7, )DRESS TEL.# � Cell (508) 280-6964 _ Nesidential CSLC5 531 HIC-169393 Est.Cost of Construction$ 1 Ste' Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) ❑ I am the homeowner ❑ I am the sole proprietor C/ 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+(c <��- Location of Facility I declare under penalties of perjury that the st 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 revocati o y and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: Owners Signature(or attachment) c fi1z�� Date: Approved By: - Date: / —2 Building ici r d ignee) Ely ADDRESS: Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes ❑ No ❑ Yes E. No 39ii 6© 1 Permit Authorization . 41141rtli mass save Form Savvgs through energy etf,crencv 2 Site ID: 3904438 Customer: Virginia Hatch I, R C I M 1 4 .L J �,) ,Towner of the property located at: (Owner's Name,printed) 23 Captain York Road 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: Date: ` f 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 -.. . .74 Fo-riwykocilo-/ 4., Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, Massachusetts 02118 Home Improvement�.Contractor Registration Type: Individual MICHAEL MCCARTHY Re 16 P.O.BOX 52 � . _ pration:Expiration: 06//15/215/2 021 WEST DENNIS,MA 02670 Update Address and Return Card. SCA 1 0 20M-05/17 ���� Gam' ,y+ 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: RReyistiatioe Exoiration Office of Consumer Affairs and Business Regulation 4 -_ 06/15/2021 1000 Washington Street -Suite 710 Boston,MA,021• --- MICHAEL MCGAII?T1 iY �. - MICHAEL F.MCCA /2 ✓ / tie r / 6 RANGLEY LN. 'a./ r/ SOUTH DENNIS,MA 02660 Undersecretary =' Not valiid..W out signature .._ weak.,of Massachusetts j n l Licensor � +Cy. Board of Buildi n9 Regulation and Sta e lidards Constr iti, sor Ms s iilf q the National RWiir' CS-05 3 { 4` ,. 2314 divot M ust2011 . Maw.J 2 ..,0 .. , . ..._.„„,,, .. ',., . IM�I,IAtIr.t+Ml�i.r. `0„.,4J.1*- W+AEt*NAL f'IsiR f+l.en lien assait6.._ .......e....re---,.r*I" ►CoIFt 1a. Ia..- OSHA 001558712 s 0 U.S.Osp.rh rnt of labor Occupelonagielety arm Huth Administration r. MichaelMichael fAcCarthy h. aa Y OPtipiefefl e:1 4tOrur aiUdHHe ► r TIO100lr s#` 32A i .s 66Ytlrofdep�ifbbe 4 • ' The Commonwealth of Massachusetts • 1 = i�G't Department of Industrial Accidents c _mini 1 Congress Street,Suite 100 _�_►_��7" Boston,MA 02114-2017 • <4.� www.mass.gov/dia lirorkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. • TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name{Business/Organization/Individual): MiChaendreCarthY Gt� KZ.t Yuy� C, Address: PO Box 52 City/State/Zip: - ------- WC3t lIIi�t �b�— - one • Are you an employer?Check the appropriate box: Type of project('required): 1.I I am a employer with '. employees(full and/or part-time).* 7. New construction 2.[J lam a Sole proprletoroipannexship and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.). 3. I am a homeowner doingall work myself. required.] 9. ❑Demolition ❑ ys [No workers'comp.insurance t 4.0 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 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 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.t • 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.[ they i'v /0„ 152,*I(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 providing workers'compensation insurance for my employees. Below is the policy andJob site information: 1 Insurance Company Name: / jc.. -t',,,,.,I Li c4>,)c , Tr Policy#or Self-ins.Lic.#: V i k/C '1 3 531 Expiration Date: 1'?•-11 CI i 7 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 certify and a � . naities of perjury that the information provided above is true and correct. Signature: ' Date: 17--l'fi t l • ' Phone#: r,S'�t') -G IC Official use only. Do not write in this area,to ke completed by city or town offciaL 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#: