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Home My WebLink AboutBld-20-004189 y .° p: _Permit# O/ 1•'' H' !Amount O `'.`' ETA n E„ ) '°'"°`° E` Permit expires 180 days from "== '="'.: j issue date BO)— Lb-y I EXPRESS BUILDING PERMIT APPLICATI E C E I V E -0 1 TOWN OF YARMOUTH _m --t Yarmouth Building Department , gF iv 'a 2jP.: 1146 Route 28 ' I South Yarmouth, MA 02664 BUILD MENT /� (508) 398-2231 Ext., 1261 CONSTRUCTION ADDRESS: '/ q 6 2)i)0 5 �/4" Al 7//�--- ASSESSOR'S INFORMATION: 1 1 /�� Map: �7 CParcel: ,+I '�//J,�_ �^ OWNER: �j � l'Vni�2,l fj i'r(, 9 & 2 l bn/ u/./ p - 5 3 > V/iSl '[•1A1�,fpE /'� PRESENT ADDRESS -TEL. # CONTRACTOR:Ai4 P "C f NAME �ADD�� ze,)-�%' TEL 2 7 rrcY 1 1esidential ❑Commercial Est. Cost of Construction$ / '� Home Improvement Contractor Lic.# ` ' P �u��O S Construction Supervisor Lic.# JD 7 7 (9-3 Workman's Compensation Insurance check one) ❑ 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 1 t (move existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: //414.5-Viiiit l I IWO— Location of Facility I declare under penalties of perjury that the statements 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 vocation of my lic se and for prosecution u der h.268,Section 1. y62/Applicant's Sieature: Y Date: Owners Signature(or attachment) /,./ Date: VL W Approved By: / Date: /3e,%20 Building i ' or designee) EMAIL ADDRESS: ' Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: a Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No ❑ Yes 0 No The Commonwealth of Massachusetts r Department of Industrial Accidents 7t41 Congress Street, Suite 100 ' Boston, MA 02114-2017 ��,�5�•''4 www.mass.gov/dia \Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): /3 4/ s Address: 3 V 4 P0 City/State/Zip:�/ ! �� /" /� el 2 Phone #: 6 Are you an employer?Check the appropriate box: Type of project(required): 1.❑I am a employer with employees(full and/or part-time).* 7. New construction 2. I am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling capacity.[No workers'comp. insurance required.] 3._I am a homeowner doing all work myself. [No workers'comp. insurance required.]t 9. ❑ Demolition 10 ] Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑ Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.EI I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. OOf repairs These sub-contractors have employees and have workers'comp. insurance.i 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(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 a new 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 job site information. Insurance Company Name: Policy#or Self-ins.Lic. #: Expiration Date: 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 by a 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$250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi under the pains dpenalties of perjury that th formation provided above/ is true and correct. Date: Signature: / a� Phone 4: f7 (l$ 775 c c 3 , . 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 Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: Crfre 0ammo4uefeaa o/P464e ieae14 Office of Consumer Affairs&Business Reguiation • HOME IMPROVEMENT CONTRACTOR TYPE:'Individual Registration Expiration 107720 -- 08/04/2020 / BRIAN MCCARTHY DB/A MCCARTHY BUILDERS. BRIAN MCCARTHY 32 CARVER RD• ( � ` W.YARMOUTH,MA 02673 Undersecretary , Commonwealth of Massachusetts tlijir Division of Professional Licensure Board of Building Regulations and Standards Constructio Wieoy.1 &2 Family CSFA-047505pires:09/11/2021 BRIAN G MCPARTNY 32 CARVER Fg) WEST YARMO,JTH ,' 3 %' • '16/Sti ltll.0 Commissioner 4144.4.4)1 / / --