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Home My WebLink AboutBLD-23-002029 , 1eel(-- •YRR`� )d i/e/ Office Use Only Permit# 3 0 ;I Amount M MJl'FT%� "� ...*s Permit expires ISO days from c-' issue date LLD — 3 —00--0Y EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department RECEIVED 1146 Route 28 r- - -- - South Yarmouth,MA 02664 OCT 1 za2z (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: g� � yt-Fcdtk.c BUILDING DEPARTMENT ASSESSOR'S INFORMATION: Map: Parcel: OWNER: )14e9; Yr`'61 Vie v � ' r�2al t'1$ ?�� _2cf� I NAME PRES ESQ t TEL. # CONTRACTOR: West Dennis, MA 02670 (cCi) '_ NAME daNaI i_6964 TEL.# Residential 0 Commercial CSC. �FstrCs�#�Construction$ �� Home Improvement Contractor Lic.# t l': 7 1'7 2, Construction Supervisor Lic.# C;y `5 Workman's Compensation Insurance: (check one) / I am the homeowner r I am the sole proprietor SA/have have Worker's Compensation Insurance Insurance Company Name: -Ft T -) Worker's Comp.Policy# t17 \,JC t=,; .'S 1 D-g 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 1/' Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *The debris will be disposed of at _ e XC Location of Facility I declare under penalties of perjury th t Zhe 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 re,vdcitivon y license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: /I� Date: JO /1)-1 1 2- Owners Signature(or attaehment)! A Vv,t-^9� Date: Approved By: Date: /6 Building Official(or desio EMAIL ADDRESS: Zoning District: Historical District: Yes No Flood Plain Zone: Yes No Water Resource Protection District: Within 100 ft.of Wetlands: Yes No Yes No �.> Lirj Z444 Permit Authorization mass save Form — tic SC.` e- �Li Site ID: 4542378 Customer: Meredith Keybl I, (e reel'j4al keyI)) , owner of the property located at: (Owner's Name,printed) 80 Mattakese Road 6 West Yarmouth, MA 02673 (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: Date: O - 15. 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: 508-568-1926 Email: Page 1 of 1 For Office Use Orly The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street,Suite 100 .=`t:t 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 liklease Print Legibly McCarthy.may L� tructivu Name(Business/Organi7ation/Individual): PO Box 52 Address: West Dennis, MA 02670 City/State/Zip: CSL-584ne IIC-169393 • • Are you an employer?Check the appropriate box: • Type of project(required): 1.Qam a employer with C employees(full and/or part-time).* 7. ❑New Construction 2.01 am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling ' any capacity,[No workers'comp.insurance required.] 3. I am a homeowner doingall work9. ❑Demolition ❑ myself.[No workers'comp.insurance required.]t 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10[]Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.[]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 These sub-contractors have employees and have workers'comp.insurance.? 13.D{ �Roof repairs 6.❑we are a corporation and its officers have exercised their right of exemption per MGL C. 14'■�'der T 152,§I(4),and we have no employees.[No workers'comp.insurance required.] *Arty applicant that checks box WI 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 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. 14rc1 #FInsurance CompanyName: L.Js�';;�• , 4. �-,,�( �hC Policy#or Self ins.Lic.#: V rl W L 3 93 j Expiration Date: .13-J is- 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• e i and penaltief of perjury that the information provided above is true and correct Signature: Date: Phoned#g;*C CA a ci 0 -oey .Official use only. Do not write in this area,to be completed by city or town official Cityypr 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 I Contact Person: Phone#: Y-4 Fes. . ez A z,J,4 aae,,,4,,,,a), Office of Consumer Affairs and Business Regulation 1 000 Washington Street-Suite 710 Boston, usetts 02118 Home Improve ctor Registration j Ir�f '.-—, Type Individual MICHAEL MCCARTHY vi •z z u .', Registration: 169393 P.O.BOX 52 . I • .'Nf`_ Expiration: 06/15/2021 1,4 , 3ration: WEST DENNIS,MA 02670 „: ;r- • . x' !wn scA 0 2OM 05J07 Update Address and Return Card. Office of Consumer Affairs 4 Business Regulation HOME IMPROVEMENT CONTRACTOR RegiT�TY, trlffNiduat Registration valid for Individual use only i, F�tratron before the expiration date. If found return to: r Eih5/10 Office of Consumer Affairs and Business Regulation : 23 1000 Washington Street -Suite 710 MICHAEL MCQ, 1Thr- �74 Boston,MA:02118 �: yr. �s F� MICHAEL F.MC ,Y1 6 RANGLEY LN. 1 7 f a-/ � i 1 / SOUTH DENNIS,like =l Not valid-4 out signature Undersecretary j / , � Commonwealth of Massachusetts [t, � Division of Professional Licensure BUILDING PERFORMANCE INSTITUTE, INC. Board of Building Regulations and Standards Road. 107 Hermes oad.Suite 210 ConsVOAlk164prisor Malta,NY 12020 .._ _ (87)274-7274 .111.Th CS-058633 0' . -.727i )✓yic�pires:04i10/202 www.bpl.org MICHAEL J :..h li � r PO BOX 62 v • 'm r„. , ,w 1 WEST DENNI&+ . Michael McCarthy 1r�KSit�CS 5t.., . o ,'- BPI(De:5o232 46 „P, K. r= ' c s` Commissioner cg, ,."(SEE REVERSE SIDE FOR DESIGNATIONS AND EXPIRATION DATES) PO cC Boxy 52 West Dennis'MA 02'670 (.56€1 ) 83 - 6 6 (( p3 on cc c.r +�,yC s(NI‹, 1 . con-1