HomeMy WebLinkAboutBLD-23-001809 Lid it) 1_5 __
R E C E \J E D Office Use Only
<? ;•Permit# t IWO 3
�,,,,�r.r.E. ) OCT 05 2022 Amount ,s ,00
// p� �;Permit expires 180 days from
' 6' ✓ BUILf }� .�1"� ;issue date
aIiQ -23 - OO !Fro I
EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth,MA 02664
(508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS: 8 _. tI&'Ct'&Je
ASSESSOR'S INFORMATION:
Map: Parcel:
OWNER: E ,/� alr:-.. i tnstrua
NAME Oar, PRES:' aka SSy TEL. #
ov
CONTRACTOR: West Dennis MA 02670 (CO:.,') )e -(:, 6 tf
NAME f' M-6964 TEL.#
O Residential 0 Commercial CSE r-: 33 HIC- konstruction$ /50 0.60
Home Improvement Contractor Lic.# j(,.' >• Construction Supervisor Lic.# .5 (a:3
Workman's Compensation Insurance: (check one)
C I am the homeowner C I am the sole proprietor /(have Worker's Compensation Insurance
Insurance Company Name: Ir,vf., 1 L w i L 4` t- 1``tt iv->, Worker's Comp.Policy# `7 V,•.)L C='3 3 1 6
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
Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing
*The debris will be disposed of at: $ '4- -3 e x .
Location of Facility
I declare under penalties of perjury th t jhe statements herein contained are 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 r vo y license and for prosecution under M.G.L.Ch.268,Section 1.
Applicant's Signature:
Date: id 15 ia'2-
Owners Signature(or attachment) '( c� -9- Date: ),!/ )01-
Approved By: `/ e ' Date: �/ "79
Building Official(or de ` ee) EMAIL ADDKESS:
Zoning District:
Historical District: C, Yes 7. No Flood Plain Zone: S Yes a. No
Water Resource Protection District: Within 100 ft.of Wetlands:
i] Yes _i No 0Yes 0 No
The Commonwealth of Massachusetts
1�--=--- —!t Department of IndustrialAccidents
;:n_. 1 Congress Street,Suite 100 •
_• fi- 'y Boston,MA 02114-2017
www.massgov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
• TO BE FILED WITH THE PERMITTING AUTHORITY. '
Annlicant Information . .- • Please Print Legibly
Mike McCarthy.Our astraacl'aarar
Name(Business/Organization/Individual): PO Box.52 - -
Address: . . West Dennis, MA 02670
Cull(508) 280-6964.
•
City/State/Zip: ,i i 1 s e., : CSL-584ne MIC-169393
Are you en employer?Check the appropriate box: • Type of project(required):
1.tam a employer with V employees(full and/or part-time).' 7. 0 New construction
2.0I am a soli proprietor or partnership and have no employees working for me in 8. El Remodeling `
any capacity.[No workers'comp.insurance required.] 9. ❑Demolition
3.01 am a homeowner doing all work myself[No workers'comp.insurance required.]1 -
10 0 Building addition
4.01 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.a Plumbing repairs or additions
5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. Roof repairs .
These.sub-contractors have employees and have workers'comp.insurance.;
6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 14.[Other ..,.,�1-,
152,§1(4),and we have no employees.[No workers'comp.insurance required.] • _
'Any applicant that checks box t!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.
•
;Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether of not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number..
I am an employer that*providing workers'compensation insurance for my employees. Below is thepolicy and job site
information. •
Insurance Company Name: A.4-444,....t.I L.ci:10-, it - ioNt.
Policy*or Self ins.Lic.#: V., Expiration Date: la I If 1.a 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 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 and penalties ol'perj frfury than the no_rnrgkon provided above is true and correct
Signature: • f a c Date:
. hst) ag 0 —Gy'
•Pone#:
r
-Official use only. Do not write in this area,to be completed by city or town official,
• City>pr 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#:
DocuSign Envelope ID:76BB8FC9-EAC4-456B-8761-179BE20BF782
-76/• -1-1( • 2.10A
4/11Plifiir: Permit Authorization
mass save Form «l' — 3-Zos'A iS" ira•ys
savm9,,Mtthogt1 energy effacrency
Site ID: __ Customer: Janet Dunphy
I. Janet Dunphy
,owner of the property located at:
(Owner's Name,printed)
83 Eldridge Road South Yarmouth, MA 02664
(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.
,-DocuSignedby:
Owner's Si �-44CBE70D7018161
ature: '�° �"
E7
9/21/2022 1 4:51 PM EDT
Date:
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
.
...,
9 °.-/0ezek,1-10.00"-medea-
Office of Consumer Affairs and Business Regulation
1000 Washington Street-Suite 710
Boston, -:,,,. .. i, usetts 02118
,,,,,..,
Home Improve ,..*; "`e., 1 :ctor Registration
-..... ........ ...„........ .
. i..,_--,,,. .._f;'. .-i.-;-::7,,,-.7.•,•7,
frN,'I!. L 7.zz 7::-.:-7. .1!--:::4_7i'le 7,\ Type: Individual • _
mickaa mcaskFrniv IA.,,,,,,,,-,,.---,--,,k., 7,,,-',...i..:.::"..i:,:fil, Refistration: 169393
Expiration: 000021
l'', ".:_,F.:.,:,,„::.:••:.-1;-;•.-?‘. ttP.
WEST DENNIS,MA 02670
1-Itt ,f,::::-‘, 17, i /.. : •.. - rz.:,1
(-.... '1-,,.,..:-.:;..........,-:."•.- ,.."
::. :...."` Update Address end Rattan Card.
SCA 1 0 20.445/17
.9Z r.o...seivasumad".4. .
Office of Consumer Maks itt Business Regulation
HOME IMPROVEMENT CONTRACTOR Registration valid for MdIvidual use only
BisthitMndhoblial before the expiration date. If found return to: -
Exatratlon Office of Consumer Affairs and Business Regidation
03t15/2013 1000 Washington
:LL Street
,i
-Suite 710 10
MHAEL ' zi BosonMA /
MLFMCt —
........'.
6 RANGLEY LN. c,'„i.,....W/•.*/ Saawst4.44* , 7
SOUTH DENNIS,MAqiite ty Not sal out signature
Undersecretary
.1 . Is
ta. COMInaPnWeanti of Massachusetts
BUILDING PERFORMANCE INSTITUTE,INC.
Division of Professional Lieensure
IP Board of Building R-,! .i. , and Standards 107 Hermes Road,Suite 210
•
Con ' , i'..0' '' • , ! Malta,NY 12020
-.... ., (377)274-1274
CS-058633 .0' :, •:- -' OSpires:ogyionorti www.bpiorg
MICIUMEL J
: :POBO) 24 . 1g0
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WEST
416_
.?•?."..".-1,-.,"..,- 4) ':. Tie
Michael McCarthz
::".•'. .t-1.4...1"-- ,-*I'-'1•!..-..!.,,-o,_;;s.:
Commissioner srfbirsinilei.,
e . "(SEE REVEREE SIDE FOR DESENATIONS AND EXPILATION OATES)
Milaei Witwthy
PO Box 52
West DennislIA'02 670
(506 60 - 6 6 `f
•