Bld-20-004125 O _Permit#
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EXPRESS BUILDING PERMIT APPLICATIO r 1 !
TOWN OF YARMOUTH A'`` ' );"?
Yarmouth Building Department BUILD a`p_-- _.j;_N 4
1146 Route 28 By _ &_ ■ .'
South Yarmouth, MA 02664 '
(508) 398-2231 Ext. 1261 .
CONSTRUCTION ADDRESS: J 3 /1cLeJ1t, f i . \.,tk.3/
ASSESSOR'S INFORMATION: •
Map: Parcel:
OWNER: 'err,c-r rw (`)-- /tit•, 5,rk ($) 53"o1"i5e-r
NAME Mike Mc* Areatistruction TEL. #
CONTRACTOR: PO Box 52
NAME West Blizanitsafts02670 TEL.#
Cell (508) 280-6964
(:residential ❑Commerci SL-58633 i13C-16j39 of Construction$
Home Improvement Contractor Lic.# (/
p �b '77>) 3 Construction Supervisor Lie.# 5 V. () `)
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 PERFORATED
Tent Duration (Fire Retardant Certificate attached?) Wood Stove
Siding: #of Squares Replacement windows:# Replacement doors: # /
Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation te
Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing
*The debris will be disposed of at: S 1 ' EI C c) f ()c r-NrNo., / l
Location of Facility t
I declare under penalties of perjury that the stateme - r are e 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 1" o cutidn der M.G.L.Ch.268,Section 1.
Applicant's Signature: Date: I l.2L/.1,
Owners Signature(or attachment) 14• .L t+L // Date: 1!) 1 U"-=-
Approved By: /..�1� Gt Date: � �26"% o
Building Official(or designee) EMAIL ADDRESS:
Zoning District:
Historical District: 0 Yes ❑ No Flood Plain Zone: 0 Yes 2 No
Water Resource Protection District: Within 100 ft.of Wetlands:
0 Yes 0 No 0 Yes ❑ No
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ENGINEERING'
OWNER AUTHORIZATION FORM
1, Bernardino Ramos
(Owner's Name)
owner of the property located at:
33 Michelles Path
(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.
Owner's Sign ure
1 -? fig
Date
RISE Engineering, a Division of Thielsch Engineering, Inc.
5 Dupont Avenue I South Yarmouth, MA 02664 1508-568-1926
www.RlSEengineering.com
- . •
,9-4 ro-n9
toeer,d1 6yz ', 4
Office of Consumer Affairs and Business Regulation
1000 Washington Street- Suite 710
Boston, Massachusetts 02118
(. 000
.....
Home improvemoit. tractor Registration
• Type: Individual
, 1:" 169393
MICHAEL MCCARTHY '
P.O.BOX 52
WEST DENNIS,MA 02670 ,.. - ' • .. ..
„. _.. , • .,,
- ,
_ Update Address and Return Card.
SCA 1 6 20M-05/17
•
ffe g49.0/n/MViemeaddrcydVea,Akirevrezekse-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:
alSilifilln1111 ill$1110211 Office of Consumer Affairs and Business Regulation
1.6929l 06/15/2021 1000 Washington Street -Suite 710
MICHAEL MC014110W, Boston,MA 1‘ /..
„021 „ ...........---
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MICHAEL F.MCCAM.: ,i: // i /_ ,
6 RANGLEY LN. .'•.',,:.'„,-4-:.,...7 ''''i ,es..s..itre a.404"
SOUTH DENNIS,MA' "02-8130 ' Undersecretary •-• Not vain* out signature
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• • The Commonwealth of Massachusetts
• �..=- i—'/ Department of Industrial Accidents
•
'i ri�_'w 1 Congress Street,Suite 100 .
;- • 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 Leeibly
Name4Business/Organization/Individual): Michael McCarthy G„s'bi.c.T'v.}. ,1.v-,c..
Address: PO Box 52
- -- City/State/Zi - WC3i PF #: OZ — --- -
P: lone
Are you an employer?Cheek the appropriate box: Type of project(required):
I.Q I am a employer with employees(full and/or part-time).*
7. 0 New construction
2.0 ram d sole proprietor of partnership and have no employees working forme in 8. El Remodeling
any capacity.[No workers'comp• .insurance required]. •
3.0I am a homeowner doingall work myself. comp.insurance required]t 9. ❑Demolition
y:cl [No workers'
4. I am a homeowner and will be10 Building addition
contractors to conduct all work on
hiringmy property. I will
ensure that all contractors titter have workers'compensation insurance or are sole 11.[]Electrical repairs or additions
proprietors with no employees.
12.0 Plumbing repairs or additions
SO Una a general contractor and I have hired the sub-contactors listed on the attached sheet.
These sub-contractors have employees and have workers'comp.insurance.t 13.❑Roof repairs
• 6.0 We are a corporation and its officers have exercised their right of exemption per MCI a 14.�tiver Sr /1,4
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 anew affidavit indicating such.
tContractors 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 Job site
information:
Insurance Company Name: N.+t•�v -1 L J ;I i 47 + /'i.t4 1 c
Policy#or Self-ins.Lic.#: ti V ci”. rs 3-S, )_an Expiration Date:_ U-►)I j)au
Job Site Address: City/Stitt/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 of perjury that The information provided above is true and correct
Sienature: Date: I)-I ant f
• • Phone#: ('c,t),ten-G IC ct
,--
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#: