The URL can be used to link to this page

Home My WebLink AboutBld-20-004128 r •• '' e - 4tYg 0 �,•/y . H 1Amount S toln, ..........E 1 Permit expires 180 days from ' t , I 1 L {issue date B y rW.. EXPRESS BUILDING PERMIT APPLICAT R I V E i TOWN OF YARMOUTH Yarmouth Building Department1146Route28LJ4NJ7 ! South Yarmouth, MA 02664 By. T 35— (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 3 r 3 w l•,,-,):„ A.,,... t'r ASSESSOR'S INFORMATION: Map: Parcel: OWNER: -1� r (...:c rv,-1I,, S-r k (- ) 31-'73.)-`/ NAME Mike Mc> hypeatistruction TEL. # CONTRACTOR: PO Box 52 NAME West Diansismigtts02670 TEL. —11 Cell (508) 280-6964 GYResidential ❑Commerci sL-58633 1 1C-16459V of Construction$ Home Improvement Contractor Lic.# I��S)'3 Construction Supervisor Lic.# 5 r_ 6 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 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 I Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: f T Ex r o ..,,,h). ,- t Y-v1,y / i A Location of Facility t I declare under penalties of perjury that the statements her ' co • ed 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 revocation of my lice d rosec on er M.G.L.Ch.268,Section 1. Applicant's Signature: , Date: I` 41)- Owners Signature(or attachment) 4` c`L Date: 1 i 3;1I) --- Approved By: Date: /—J�/p Building i • or designee) ADDRESS- Zoning District: Historical District: 0 Yes ❑ No Flood Plain Zone: ❑ Yes - No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes ❑ No I Stu 2.3i 3-3 al Okk Permit Authorization mass save Form c - ;1-2_3 Q.3 Savings eouys ewer rthneflcr 7 Site l D: 3 1 L 3 I 0 7 Customer: Aif3T i C i 0 C.oLr fc b t l C.O Co‘r v4I h 0 ,owner of the property located at: (owners Name,printed) 33 wa5t,t,5—tot, Ave west- 7e.cmoirrIN (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 Signature: YeitAARA-0 Date: 1-1. /1 I /I 1$ . •rh+A'yi.'M d, .4" o pb M eb ft'ot +or t' a s'«� P 4.,t o a ce.Y.e"vn :`" ". .. '+ ... . 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 4 FO- . d Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, Machusetts 02118 Home Improvem -C itractor Registration • Type: Individual MICHAEL MCCARTHY '` -~ 3 Registration: 169393 /15/2 Expiration: 06/15/2021 P.O.BOX 52 WEST DENNIS,MA 02670 Update Address and Return Card. SCA I Cr 20M-O5/17 • Me rommetetaevate.‘eyedga-Akze,feaWZI 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: flegistiation, eaRiliftlial Office of Consumer Affairs and Business Regulation 06/15/2021 1000 Washington Street Suite 710 MICHAELMail**, r ;' Boston,MA,02118' /,; � j / ff �y, MICHAEL F.MCCAr 6 R '' Not vald-w out signature SOUTH DENNIS,MA 0266D ' Undersecretary . G Pb4.: 'P--r--------------k-'"----w-----dr------""u""i"jlialw"1""bkll. : . . Boaratl of f eNgit aF i,ire ea e Cons sedStaitdetdet • Mae CS - $litlafsi� • . ;, '''''' .11.1119,Niliafillar. mama • : Ill s • N#310t1*e.PISSR ' . s . ; 1 Nte•e&Ita iwewies0 . : • Mb ....e. s... • . • ,. ..„ ....., . ....r os 001558712 y li ,s . UAL oep.a+rnc of labor . •..t anti Huth Paimit lkat Michael McCarthyr w::m.' p."-o...:o':l-k:9;k::'..7o .e19d0.arQ Po,. pl'f,* 4 a 5st'> 5Wp(rdi �" a : . r�`..�✓ e, u fie/ ` t ' s," • • The Commonwealth of Massachusetts • 1► Department of Industrial Accidents • __cY1i= 1 Congress Street,Suite 100 -�v1t- • Boston,MA 02114-2017 • %:..7..0.r www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. • TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Leeibly Name(Business/Organization/Individual): Miehe McCarthy C 5_41mA•4. ... :E.-,c. Address: PO Box 52 — -- City/State/Zip: -----------___.-_.WC t iili—� b�_. - ---- • Are you an employer?Check the appropriate box: Type of project(required): l.Q I am a employer with 1.-. employees(full and/or part-time).* 7. ❑New construction 2.0Iamdsoleproprietoroipugrershlpandhavenoemployeesworkingformein S. ❑Remodeling any capacity.[No works s'comp.insurance re• quired.). , 3. 0 I am a homeow•ner doingall work m L9. ❑Demolition ❑ Ysel [No workers'comp insurance required.]r 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 0 Building addition • • ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions S.Q lame general contractor and I have hired the subcontractors listed on the attached sheet Roof These sub-contractors have employees and have workers'comp.lnsurancet 13.❑ repairs We area corporation and its officers have exercised their14.�'6ther Z �.1,,,� • 6. ❑ rightofexemptionperMOLa • 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 infomntion. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. *Contractors that check this box must attached an additional sheet showing tie name of the sub-contractors and state whether or not those entities have • employees. If the subcontractors have employees,they must provide their waken'comp.policy number. I am an employer that Is providing workers'compensation insurance for my employees. Below is the policy and fob site Information: Insurance Company Name: Ah...'Ft'c,n...I Li cb;I i 4•.../ 4- ''F1'arc Ins• , Policy#or Self-ins.Lic.#: y V'J WC v 3� 1.ag Expiration Date: 11)►)'I at • 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$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 //// , 1_ - ' of perjury that the information provided above is true and correct Signature: Date: 1 Z- r 0 r# • ' • Phone#: (c k) 1 -(IC b OfficialI . use only. Do not iprite 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 S.Plumbing Inspector 6.Other Contact Person: Phone#: