HomeMy WebLinkAboutBld-20-003697 OTC,yg-- ;Utrice Use Only
�' ' Permit# /
r O h'� H 'Amount
so
.�(MAATT. R Ab(, '1
°"0"•'�° c �Permit expires 180 days from
0V I✓l 7A V J�"30? i issue date
EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261 (C..�-6 Q Z 0
/ C C.
CONSTRUCTION ADDRESS: [ o'7 i Z� J - 142:
ASSESSOR'S INFORMATION:
Map: Parcel: { v,>
L.
OWNER:6 f�f l j 20 oar g�AIVIE PRESENTAD RE/ ��$,� TE2k(-,>+9 7/57
CONTRACTOR: AN V/ 6G �f1Y � "'C E�.li�" PO W ,1 4 c�7 7 c cc3'
sidential ❑Commercial Est.Cost of Construction$
D
MAILG ADDRESS
,Home Improvement Contractor Lic.# /9 7 7d3 Construction Supervisor Lic.# 0/7 cD
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:# 9Replacement 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: )"/ik1P— "/ ( M ' "12--
Location of Facility
I declare under penalties of perjury that the statements erein 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 o evocation of my lice and for prosecutio i .L.Ch.268,Section 1.
Applicant's Signature: Date: 32/,) t
Owners Signature(or attachment) { Date: 1-/3V. 0/9
Approved By: Date: 2 C%"
Bu" g cial(or designee) E ADDRESS:
Zoning District:
Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes ❑ No
Water Resource Protection District: Within 100 ft.of Wetlands:
0 Yes 0 No 0 Yes 0 No
' The Commonwealth of Massachusetts
_ Department of Industrial Accidents
m.ziett:1 1 Congress Street, Suite 100
-'•`_ Boston, MA 02114-2017
M�s�• www.mass.;ov/dia
\Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information PIease Print Legibly
Name (Business/Organization/Individual): /3 /
Address: 3 01, G"7 /1-72- 12-4,
City/State/Zip: !w'j / �3#_ Z"v 7 .7(3"'
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 I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling
a capacity. [No workers'comp. insurance required.]
9. Demolition
3.. I am a homeowner doing all work myself. [No workers'comp. insurance required.]t
10 E 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.E Electrical repairs or additions
proprietors with no employees.
12.❑Plumbing repairs or additions
6.❑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.
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.El 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.
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 4 or Self-ins. Lic. 4: 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 certify under ze p '►c nd e I 'es er' r at the information provided above is true and correct.
Signature: Date: 1 3/i
Phone#: 2,6 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::
•
' Office of Consumer Aftai s&Business Regulation
HOME IMPROV AENT CONTRACTOR
TYD,E,individual
expiration
1O7?,, ,. 08/04/2020
/ BRIAN MCCARTHY ' `
DB/A MCCARTHY BUILDERS;;
' , .
BRIAN MCCARTHY , t__.11,
32.CARVER RD .,.
W.YARMOUTH,MA'02673 Undersecretary
•
•
14�. Commonwealth of Massachusetts
3 Division of Professional Licensure
Board of Building Regulations and Standards
Constructio� �1' fit 1 &2 Family
CSFA-047505 f
i spires:09/11/2021
BRIAN G MCARTi�?N
32 CARVER 1' t ,.. m
(----- WEST YARMOpTH • 1 "`.;3 '
Commissioner ��