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Home My WebLink Aboutbld-20-003703 3,,- ;YR - 101lice Use Only o , R iPermit# O . - ` - H 1(Amount ��"� '-� T MATACM [3[J�' �""°""°..4 , {Permit expires 180 days from .:__ •,:. ^ {issue date B U,- EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 C(44 39 j�Wc (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: ) L( /1 C1Th ✓ ct----l ASSESSOR'S INFORMATION: Map: Parcel: ��;� I OWNER: / � Si: S"^pL 77ti—el,._4iy`rc NAME MikeMcCarthy fDb ' S° TEL. # PO Box CONTRACTOR: West Dennis, MA 02670 NAM Cell (508) 2 ILgye DRESS TEL.# esidential C4SL 68633 H�IVC-169393 Est.Cost of Construction$ I S Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) 0 I am the homeowner D I am the sole proprietor 2'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: t S -e'Y: (d Location of Facility I declare under penalties of perjury that the at en ern 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 revocatiop o li for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: //;' Date: I 16)-- )-P' Owners Signature(or attachment) l A 1'v..,L-., Date: Approved By: Date: / 2 2.,::::,Building ial designee) EMAIL DRESS: Zoning District: Historical District: 0 Yes No Flood Plain Zone: E Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No gy10 Cell - RISE 2 056d � k. ENGINEERING' 3 OWNER AUTHORIZATION FORM Nahir Ojeda (Owner's Name) owner of the property located at: 14 Smith Road (Property Address) South Yarmouth, 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. Owne ature Date RISE Engineering, a Division of Thielsch Engineering, Inc. 5 Dupont Avenue I South Yarmouth, MA 02664 1508-568-1926 www.RlSEengineering.com Office 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 WEST DENNIS,MA 02670 Update Address and Return Card. SCA 1 0 20M-05/17 .11;3 Fewuneretuity/...igezAJezeifilAte/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: asgighligh Expiration Office of Consumer Affairs and Business Regulation 1.3939 ,._ 06/15/2021 1000 Washington Street -Suite 710 MICHAEL MCCARTHY.- ,,-...-----, ' Boston,MA 02116' /,.• , MICHAEL F.MCDAFert4t- ,' 6 RANGLEY LN. • --- ' , ,/,.......t a.72e40. - / /i 1 ./ SOUTH DENNIS,MA-02660 ' .:Undersecretary ' Not valitcL4 out signature 4 4 „.„--.. aoardecifivnonr : Ittaireuletietinses,uretts .... _ ,...4 ip ' • Michael McCarthy sBuilding„miaSosts and Standards likkealthy Constipation Constr ,..W1111161601,1rVisor ' Kos suasSisitiny eeRipieteglthetiationd Fiber' C8,058633 ..-- Woke,tratning Mona . . IridllyafAugust2011 . MICHAEL J ' -.- "°•.'". Posorft ....., - -44 ! VVEST wen*, a 04- .. i f i " IAN 'A\'.4rik.• ' . Ai 1 VIATICONAL masa NM atillituabasesiebseasof • ....................,........... COMMtellitOrter 1,416.• AL' % . LeoBOitteemna,... - ...• - - ' , - osHA 001558712 • . ric-46.-iga- sow.,.. -.- . tiabohnikkiwirm U.S.Oepertervint of Labor • .-, _ COW OrtMingatea : '• ' OccuPlibmiltldsfy end Health Administration . , 'r-.. • : ' •Michael. McCarthy miwconiatic . . 118"4"laMr441084."14)410uraccuPasomiSiiibltalliffeelei - , • .t*".!•2141Iii.00 1"i't-•,-1...s,,i _ !'-',." , Wit%CCM*gt- • - -z 4214001043orifi neemi fibestt ”.•- tri!lt! ' ' '.:'-' .. "teatime ..0' 4. •: .....,-.-..:.. • • . - . ,: . -' %•%.--%%.,4%.1.7.1i4;..-.- ;:i ' ; • The Commonwealth of Massachusetts •_ I Department of In dustrialAccidents _EY1-a 1 Congress Street,Suite 100 . -Ir _+eT_!o 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 Legibly Name(Business/Organization/Individual): rfthael McCart y '- Gr. Address: PO Box S2 - -- City/State/Zip: - ------- we3t onel#: • b�— -- -- — Are you an employer?Check the appropriate box: Type of project('required): 1.0 I am a employer with 1. employees(full and/or part-time).* 7. ❑New construction 2.01 am a sole proprietor of partnership and have no employees working for me in 8. El Remodeling any capacity.[No workers'comp.insurance required.]. • • 3.01 am a homeowner doing all work myself.[No workers'comp.insurance required]t 9. ❑Demolition 4.01 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. 12.0 Plumbing repairs or additions S.O 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.❑We are a corporation and its officers have exercised their right of exemption per MOL c. 14. er �►'�>✓�•+,., 152,§l(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 rnew 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 subcontractors have employees,they must provide their workers'comp.policy number. Iam an employer that isprovldingworkers'compensation insurance for my employees. Below is the policy and Job site information: Insurance Company Name: AJc+ 'ens Li cJ>;1 i.l•../ 4- 'f"i,rc -27-%5• Policy#or Self-ins.Lic.#: V1 k/C '13 57 y Expiration Date: i -)i5-/17 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 punishablebya 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,y ' i des of perjury that the Information provided above is true and correct Signature: / Date: 11-I+fJ t F • phone#: -G IC tt Official use only. Do not write in this area,to be 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 Cleric 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: