BLD-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 ,
•