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Home My WebLink Aboutbld-20-003706 S value use unl .01.•YAR`t Y �'� C 1Permit# Ou. • . H Amount �� G .ATTACH [S[ 49 i a'tO+Mntcoo End ;Permit expires 180 days from issue date 5L0-- 0--'370 (0 EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH • Yarmouth Building Department 1146Route28 South Yarmouth, MA 02664 C IC-14 3i(3/: (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: S) Ic9,t`;V f.)- .:t L� ASSESSOR'S INFORMATION: Map: Parcel: Sc, Ilk., I1,.,I+1,... OWNER: NAIMl ike McCarthy Construction s"'L (c�`) (>r S-1-7-i,— PO Box 52 PRESENT ADDRESS TEL. # CONTRACTOR: West Dennis, MA 02670 NAME Cell (508) 280-69ING ADDRESS TEL.# t7 esidential CSL-580rciaiHIC-169393 Est. Cost of Construction$ 6G= Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) � 0 I am the homeowner ❑ I am the sole proprietor ❑Wave 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 1. 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 statements er containe e tru orrect 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 tic d f ro ut nder M. .L.Ch.268,Section 1. Applicant's Signature: Date: 11) I .l.a Owners Signature(or attachment) / 'I c LJ— Date: Approved By: 4'i �� Date: / ---.2 �4 Building Official( si EMAIL ADDRLA1S: Zoning District: Historical District: 0 Yes ❑ No Flood Plain Zone: ❑ Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes0 No R I SE sue _ c§-k _2� ENGINEERING" OWNER AUTHORIZATION FORM 1, Jo Ellen Montbleau (Owner's Name) owner of the property located at: 52 Eldridge Road (Property Address) Bass River, MA 02664 (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. O er's Signature 6.-Vill4j6fj—td Date RISE Engineering, a Division of Thielsch Engineering, Inc. 5 Dupont Avenue I South Yarmouth, MA 02664 1508-568-1926 www.RlSEengineering.com • ,9---4 -?/0-,?,(y}eebilo-/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: 06/15/2021 P.O.BOX 52 WEST DENNIS,MA 02670 Update Address and Return Card. SCA 1 0 20M-05/17 ffe Fewzmnimieac/..iga-J,Jaciee.se/4 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: aggietikkg Expiration Office of Consumer Affairs and Business Regulation 40939 l --->.... 06/15/2021 1000 Washington Street -Suite 710 MICHAEL MCCO-11.RY-T':;:i."-.'„-r — Boston,MA ozogg / /I''''' / . / / .?/ . MICHAEL F.MCCAFFT-t /2 /s • / u I / 6 RANGLEY LN. -.•s --- ..-: , .1‘.4444,114 1,414414. SOUTH DENNIS,MA 02.1111• r ''.. Not valid4i out signature Undersecretary ii . r.... Co ,4"7 lit notionwealth of Mossachturetto' prvildon or ProteestorialLicens - . wawa mccmhy. Board of Bliiiding ,00fts add 41.1ndee rda , '• .:, lailiCarely CIIMIPtillett011 COnStr~itOplityVhcor . CS-05863 ..-- Kiwi suceilligiOPOneteletedttieflational Fiber• .:. i Celkieee Traligng Okbeee •:::: ':•:-;-:-. Vor. . , ,, 1 V ?.; g: • 21d day OfAugust 2011 . ; mICHAELI -,... . ' Ater-L' 2» : . , Pe BOX12 ; ; -. ::• ;-iit;••!,i : WEST teripasift , ;';" ne ---p,.. N. .f 1... '' .14. • ; VIIINe.tailmalifbar, "NV-117.11/4.• 011metereallise itaisaassoo.PHARR 4. Ifelsvanaltasombesese ..........................." COMMliehnter 'c..t. AFL- , . 44F1114MMoun...e..... - - ..., . • ....--- . OSHA 00155871.2 • ‘ :. 66-62010.. ... .,. .:::' - 41.0"hatigniteggrat— . . . cow . . .U.S.Oepertment of Labor ; ••! , - OCCUPanonalOaletY Ind Health Administration Michael McCarthy ;4%44ifliffogiat4 , . . . hisWFAINOW04,0018•1040,0r°1624i,x-istSifet,Yoffriligifth ,' ' -. - -,- .' - . '''. . - "• .Sr.,. . .....z. piteeptorClilaiussailithouttoriMaitree :y! T.! .,7'. ,.1,9/P7 ,,..- ---*---;:i4-.9.-427---,.. - ..... ..:„‘„,..,‘, •:,-,,,,?::-...., • ..............-..-c.z.- .; -. - . , , ••• e • , ' -• s . • The Commonwealth of Massachusetts • l!�_ ��►/ .Department of Industrial.Acciderds • _ie18�=a 1 Congress Street,Suite 100 . It _1►_ • Boston,MA 02114-2017 • www.massgov/die • Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. • TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name.(Business/Organization/Individual): Michael McCarthy CGr ,►�.��-v�� ,.,�. • Address: PO Box 52 - - City/State/Zip: - ------- Wed Pnnel#: 02b�— • Are you an employer?Check the appropriate box: . Type of project(required): 1.13 I am a employer with '(. employees(full and/or part-time).* 7. ❑New construction 2. I am a sole proprietor partnershi and have no ern l0 8. ❑Remodeling ❑ p p yeas working forme in 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 4.01 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 13.0 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. ther �r a//•t+. 152,11(4),and we have no employees.[No workers'comp.insurance required.] . !Any applicant that checks box SI 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 and fob site information: - Insurance Company Name: jc.+1'on,I Li ci>;I i 47 ♦ "Fi f't Tr.S Policy#or Self-ins.Lic.#: V ci k/C 3'I•- 57/ Expiration Date: I'a—)►C)i• 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 e ns, ' 'enaities of perjury that the information provided above is true and correct Signature: Data: i ) F • • Phone#: 'to-G ICE, Official j�icial use only. Do not write in this area,to lie 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#: