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Home My WebLink Aboutbld-20-004238 • $ • ` `. <Permit# y,� O , # . 9-1lAmount k ` 11ATTA II GSf �' !Permit expires 180 days from issue date B -2,0- q -2_ 3 RECE ED EXPRESS BUILDING PERMIT APPLICATI ! TOWN OF YARMOUTH k FEB (j`2 2U2U Yarmouth Building Department 1146 Route 28 3t;n T South Yarmouth, MA 02664 - ` (508) 398-2231 Ext. 1261 • CONSTRUCTION ADDRESS: 3 q �5��. s J� ASSESSOR'S INFORMATION: // Map: Parcel: L OWNER: c.;:•, (Sob 35.t(' NAME Mike Mc hJeatistruction TEL. # CONTRACTOR: PO Box 52 NAME West BannisOtilAs02670 TEL.# 1 Cell (508) 280-6964 'Residential ❑CommerciiSL-58633 m1C-16F9 of Construction$ /coo Home Improvement Contractor Lic.# 1( ' 5 (3) 3 Construction Supervisor Lic.# , , Workman's Compensation Insurance: (check one) ❑ 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 ✓ Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: S EX C k-s,r14.,5 A Location of Facility I declare under penalties of perjury that the statements rftyh 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 of my lic rosecutio der M.G.L.Ch.268,Section 1. Applicant's Signature: Date: ) J?`- Owners Si;nature r attachment) T (Q Date: 1 1).i?-=-- Approved By: Date: '3 a`() Building Official(or designee) EMAIL ADDRESS: Zoning District: Historical District: 0 Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No ❑ Yes ❑ No v 3 q`f RISE " pa-y((. ENGINEERING OWNER AUTHORIZATION FORM 1, Lois Shaw (Owner's Name) owner of the property located at: 35 Hastings Avenue (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. )4Pcrt y_ ea Owner's Signature (/.?/L Date RISE Engineering, a Division of Thielsch Engineering, Inc. 5 Dupont Avenue I South Yarmouth, MA 02664 1508-568-1926 www.RlSEengineering.com • - The Commonwealth of Massachusetts n / IndustrialAccidents __•��c Department o.f Jg1�= a 1 Congress Street,Suite 100 • =t= � Boston,MA 02114 2017 • wow mass.gov/din Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. • • TO BE FILED WITH THE PERMTITING AUTHORITY. Applicant Information Please Print Letribiv Name.(Business/Organization/lndividual): Michael McCarthy CC„•.s'ra.s_i-v„s. Address: PO Box 52 City/State/Zip: one • Are you an employer?Cheek the appropriate box: Type of project('required): I.1 I am a employer with I... employees(MI and/or part-time).* 7. ❑New construction 2.0I am d dole proprietorofpartnership and have no employees working forme in 8. 0 Remodeling • any capacity.[No workers'comp.insurance required.]. • 9. Demolition 3.01 am a homeowner doing all work myself[No workers'comp.insurance required)* 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 0 Building addition • • ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with 110 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 13.1pRoof 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 MCI a 14.[�tirer Sr i 1s J 152,11(4),and we have no employees.[No workers'comp.insurance required.] • *Any applicant that checks box if 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 a'naw 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 providingworkers'compensation insurance for my employees. Below is the policy and fob site information: . Insurance Company Name: Nc!r c.v..-t Li c,b;1 47 + 1 c• Policy#or Self-ins.Lic.#: tiV c]WCc3 Expiration Date: 1.2�))i 1 a3 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$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. . I do hereby certify and e ,a - , of perjury that the information provided above is true and correct Signature: j/ Date: 11-brill f • ' Phone#: -C U Li Official use only. Do not write in this area,to ke completed by city or town offlciaL City or Town: Permit/License# Issuing Authority(circle one): • 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 5 . . - ro-nzina-/?,eveer/GWc>'. 4- Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, Mchusetts 02118 Home ImprovemeltContractor Registration • Type: Individual Registration: 169393 MICHAEL MCCARTHY Expiration: 06/15/2021 P.O.BOX 52 WEST DENNIS,MA 02670 y„ Update Address and Return Card. SCA 1 e5 20M-05/17 • Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Individual before the expiration date. If found return to: Realetkation Exoiratfon Office of Consumer Affairs and Business Regulation 06/15/2021 1000 Washington Street Suite 710 MICHAEL MCCP 1 F4'O,t' Z't ft, Boston,MA,0211S` / MICHAEL F.MCCAI el u 1.1 / 6 RANGLEY LN. 4. "4 SOUTH DENNIS,MA`02660 Undersecretary 4 Not VAl> i out signature ,f,.r? ,, °'fin BOard o Wit`fate .. led S ilfdar �► ns Mips l salad Flt a.. ? cS=O�I •S nodlyef �l1 - LJ t$i ii - .,-- • weal.esitirsirmo,a • �1411iorsAir . • • .�? �5 - • : Olamilwitiblis • NATION AL roan* • I 4,.911tla ars : . O ;001558712 y `"` 4 "*': :;_ r Of 1Ab0► • OactatelkmaMiatsty and HalikAdn ott .. t f icltae McCar .- 7.1.. l • _ _` : ~' s Y " �' hd< 1 1*/0ll oI auit►4,411:QOON:#7 jat def klfJ� i _' t '! - - ....f .- . , r',..:Z. ,- ., 4r",'"AL y - .,ye , 3 erj=-44 ' _ ::.ir