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Home My WebLink AboutBLD-23-005867 Y ice Use Only aR`�o L jjl1�• Z3 'OD-� �(0 //z/ Permit# ' H !Amount —)5,O '.f/�"10 MATTA .,.f st 4''' , !Permit expires 180 days from - '`"'.. issue date EXPRESS BUILDING PERMIT APPLICATI r c TOWN OF YARMOUTH D Yarmouth Building Department 1146 Route 28 APR 21. 2023 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 BUILDING DEPARTMENT CONSTRUCTION ADDRESS: ! G° �w"!ai `ZArtyyli 13 /C __PD "'v H?i - ASSESSOR'S INFORMATION'. /� Map: Parcel: 9/ 7V377 - /Y-427 OWNER: 6�'/ & 6 krp I )9Prog PAv c- a 6241 ,0-, r? "Pfro c/ NAME PRESENT ADDRESS . 'e TEL. # CONTRACTOR: /3 1r� �+�/!� in CG ,e9c P C y� PP ii , i v R lQ.59 NAME MAILING DRESS TEL.# `Residential /❑Commercial Est. Cost of Construction$ G � D U Home Improvement Contractor Lic.# to-2 ?9- Construction Supervisor Lic.# 6 '7 5 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 ` J -t..— ( emove existing* (max. 2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at: -75/7(ym z rfr ,S�F�'��M �`�� Location of Facility I declare under penalties of perjury that the statements erein contained are true and co ect to the best of my knowledge and belief. I understand that any false answer(s) will be just cause for denial or evocation of my o sy�etion un r . .Ch.268,Section 1. b Applicant's Signature: C'/ Date: c�e92 Owners Signature(or attachment) l �/y Date: /e-"/ 3 Approved By: ✓✓✓ /� Date: r'21—2 Building Official(or design EMAIL ADDRESS: Zoning District: Historical District: ❑ Yes E No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft. of Wetlands: 0 Yes 0 No 0 Yes 71 No The Commonwealth of Massachusetts f.�► ''. 1, Department of Industrial Accidents � 1 Congress Street, Suite 100 '- lL Boston, MA 02114-2017 ,r 5,,•�' www.massov/dia .g Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): /9 C6--, `—//V--1 Address: 3 C4, /,A ( 2-0 . City/State/Zip:b /9,2A--. !A5�3 Phone #: 4-DT --2 7 6 ? V Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with employees(full and/or part-time).* 7. ❑New construction XI2. am a sole proprietor or partnership and have no employees working for me in n 8. ❑ Remodeling y capacity.[No workers'comp.insurance required.] 9. ❑ Demolition ` 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]I. 10 ❑ Building addition 4.0I 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 11.0 Electrical repairs or additions proprietors with no employees. _ 12.❑Plumbing repairs or additions • 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.!2" Roof 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. 14AOther -40 152,§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. 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 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 certify under the pains nd naltiesAf js j Adow h• information provided above is true d correct. ,�`/ )� `� Signature: � Date: � vC Phone#: ---27-- ! 2,6 ?Q r 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#: Commonwealth of Massachusetts Division of Professional Licensure ' Board of Building R ulations and Standards Constructio 1 &2 Family CSFA-047505 spires:09/11/2023 BRIAN G MC A- r • 32 CARVER g . ' dr.' WEST YAR *' ?, ''C Commissioner Cit,It °. DEkIJJ Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYIEE Individual Registration; expiration - t , 08/04/2022 . BRIAN MCCARThy i ,D ',' D/B/A MCCARTRN*IL RSA BRIAN MCCARTI Y w f 32 CARVER RD ',,`a ,,../ ' i'' W.YARMOUTH,MA 02848 l Undersecretary , •