HomeMy WebLinkAboutBld-20-004127 v �•Jra Permit#
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``°4.7,0 End ^ 'iPermit expires 180 days from
6LD— 11) —lf(7j- Jissue date __ ___
RECEIVE '
EXPRESS BUILDING PERMIT APPLICAT ---- ..
TOWN OF YARMOUTH JA ► 1)
Yarmouth Building Department �''
1146 Route 28 Bul
South Yarmouth, MA 02664 By.
(508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS: S S /1-1,4-sks;..9c Or. Y r.,t-
ASSESSOR'S INFORMATION:
Map: Parcel:
OWNER: l'-• 8.^:rt,, .INti CZk) '' 2—“Os
NAME Mike Mc> h�struction TEL. #
CONTRACTOR: PO Box 52
NAME West Dianorisalggs02670 TEL.4
—! Cell (508) 280-6964
GYResidentiat ❑CommerciiSL-58633 HIC-16 39V of Construction$
Home Improvement Contractor Lic.# I(31 jl 3 Construction Supervisor Lic.# 5 ' (, 5
Workman's Compensation Insurance: (check one)
0 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 PERFORMFD
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: f `.J Ex r o 5,1 4- i.mac yy-N, Ii A
Location of Facility i
I declare under penalties of perjury that the stateme h contain are true 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 m for pr cution+rrid i LG.L.Ch.268,Section 1.
Applicant's Signature: r'"' / Date: I //C I "
Owners Signature(or attachment) • .)_c._ Date: i/) 1?. a,-
Approved By: �s�� "�' ' Date: /!a
Building Official(i es' e) EMAIL ADISS:
Zoning District:
Historical District: 0 Yes ❑ No Flood Plain Zone: 0 Yes 0 No
Water Resource Protection District: Within 100 ft of Wetlands:
0 Yes 0 No 0 Yes 0 No
i ) > 362 'ic26
411/ft Permit Authorization
mass save Form c -,) - r� zvs-,/ ' 12.3
swims through energy rff *rcy
Site ID: 3921229 Customer: Janis Brinker
t6 I'� r I, j r ( �- `� owner of the ro located at:
property
(Owner's Name,printed)
55 Marshside Drive Yarmouthport, MA 02675
(Property Street Address) (City)
hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed
below to act on my behalf and obtain a building permit to perform insulation and/or weatherization
work on my property.
Owner's Si ature: G�tiN
6n
r, ,,,,,,i,,91
Date: iZ i7 /
s,4 tv _ . .:. x F - -,, : r c .. ,, :;.-t :<„4 , ^ M t b •_S t: s.,- 5 >d.V r ea ;k : r S& 0 4k
FOR OFFICE USE ONLY
We have assigned the following Mass Save Home Energy Services Participating Contractor to the
above referenced project:
Participating Contractor Date
Name: RISE Engineering
Phone: 401-784-3700
Email:
Page 1 of 1 For Office Use Only
Rev.102015
•
The Commonwealth of Massachusetts
• 1 —: _!/ Department of Industrial Accidents
1 Congress Street,Suite 100
3 • Boston,MA 02114-2017
.' •,�,;�+ram www.massgov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
•
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Lefibly
Name(Business/Organization/Individual): Michael McCarthy
Address: P0 Box 52
- -- City/State/Zip: - ------ WC3t one : �02 — --- -
•
Are you an employer?Check the appropriate box: . Type of project(required):
1.j lam a employer with C. employees(MI and/or part time).* 7. ❑New construction
2.0I am d sole proprietor of partnership and have no employees working forme in 8. El Remodeling
any capacity.[No workers'comp.insurance required.]. •
• 9. ❑Demolition
3.0I am a homeowner doing all work myself[No workers'Damp.insurance required.]t
4.❑I 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
coo r nix"ith no employees.
12.0 Plumbing repairs or additions
50 I am a general contractor and I have hired the sub-contractors listed on the attached sheet 130 Roof repairs
These sub-contractors have employees and have workers'comp.insuraneet .
6.0 We are a axporation and its officers have exercised their right of exemption per MUL c. 14.[ ttea Sr�,�•/+
152.11(4),and we have no employees.[No workers'comp.insurance required.] •
*Any applicant that checks box II must also fdl out the section below showing their workers'compensation policy infomiatioa.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. .
kbntractors 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..+1‘v .I Li ;I i•-, + ►mot: T►"S•
Policy#or Self-ins.Lic.#: tiV cl W( - 3S• Expiration Date: u. f))a
•
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 81,500.00
and/or one-year Imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 8250.00 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 said e ,a • 'es of perjury that the information provided above Is true and correct
Signature: / Date: 11-I'sli f
• • Phone#: (ik) ?- -G SG e.,
Official use only. Do not write in this area,to ke 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#:
e74 gz� A
Office of Consumer Affairs and Business Regulation
1000 Washington Street- Suite 710
Boston, Massachusetts 02118
Home improvemOltpcsntractor Registration
• Type: Individual
' Registration: 169393
MICHAEL MCCARTHY Expiration: 06/15/2021
P.O.BOX 52 "'-
WEST DENNIS,MA 02670
,*t
Update Address and Return Card.
-
SCA 1 A 20M-05/17
...9Z rexininarx 1i a . .ise+//4
Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only
IndiVidual before the expiration date. If found return to:
on Office of Consumer Affairs and Business Regulation
06/15/2021 1000 Washington Street Suite 710
MICHAEL MCC, ,` -Q /;; Boston,MA,0211$`
/
e f �,
MICHAEL F.MC / '/
6 RANGLEY LN. :',_ " <„
.
S,(,.r..N'CG•,i.
SOUTH DENNIS,MA=02860 r Undersecretary >' Not val out signature
- ; *ii D weft of MrlssachU
B+escd of By �aF t�iea;a
Cans andsor
.j seI M/itl drl land iAilif,.. + $ f{
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U.B.�eltment of labor .<' , ��Ylyrjotworfortitsidat c
Oacuffidanskaalatyend '� #% :w :, .
Michael McCarthy