HomeMy WebLinkAboutBLD-23-001421 Oa•Y``IR
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C ire �` Office Use Only
R E I �/ E D Permit# l".,O LI 3 /
""''t^ " Cft� a. Lt3Oj
K,OE L'S 14 2Permit expires 180 days
•
issue date
BUILDING DEPAR
EXPRESS BUILDING PEBy
R APPLICATION 6/1-i
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS: (1 61.-Nkf Cf.
Vre-e 4-
ASSESSOR'S INFORMATION:
IMap: I Parcel:
OWNER: �y,,..t Irk k'IN)'", s ,.�.
AME �_ ,a, P S��E`� bft'Ut: TEL. # 'S'(/—► ('G
CONTRACTOR:
<Cllr Y TEL. #
NAME Westflennic MA 026'70 (SC is) ,)E -6 C Y
-@1fth-6964 TEL.#
❑Residential 0 Commercial CSL .5 }6 gr�n r,
�33 � C�S��$13Construction$ (,,, (J 0
Home Improvement Contractor Lic.# )L5/,
Construction Supervisor Lie.# CS63
Workman's Compensation Insurance: (check one)
I am the homeowner G I am the sole proprietor T/have Worker's Compensation Insurance
Insurance Company Name: i-, , I L<b,1'+` + r-�iL
r Worker's Comp.Policy# kitj 4../(,to-3-2 !ai
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: "� e ACC v
Location of Paciliri
I declare under penalties of perjury th t the 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 refvd y license and for prosecution under M.G.L.Ch.268,Section 1.
Applicant's Signature: j 7
Date. aa-.
Owners Signature(or attachment)• f
mil, 1
Date:
Approved By: �'�� _
Building Official(or desi•.,.fie) EMAIL ADDRESS, Date: 04�
Zoning District:
Historical District: Yes No Flood Plain Zone: 2 Yes
No
Water Resource Protection District:
Within 100 ft.of Wetlands:
Yes No Yes
2 No
RISE �< tY3 I96Ss-( t2
ENGINEERING"
OWNER AUTHORIZATION FORM
Lynne M Hutchinson
(Owner's Name)
owner of the property located at:
24 Center Street
(Property Address)
Yarmouthport, MA 02675
(Property Address)
hereby authorize
Subcontractor(to be filled in by office)
an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building
permit and to perform work on my property. This form is only valid with a signed contract.
Owner's ignature
�Jb-aa
Date
RISE Engineering, a Division of Thielsch Engineering, Inc.
765 Attucks Lane I Hyannis, MA 02601 1508-568-1926
www.RISEengineering.com
t 9.4- 6/22,-)?,0,4e067,,di 94-,&afiloia04).ef4-
Office of Consumer Affairs and Business Regu1ation
1000 Washington Street- Suite 710
Boston, itticIsskichusetts 02118
Home Irnprovetractor Registration
.... .....„,....,.
-, Type: Individual
)44ii.:::: s.,..-2..-;-/.', ..-i:--:::....-:::1.S'','I Regis-ma/ion: 189393
MICHAEL MCCARTHY y,z , ...,--,..1:-:-,:,. .::--..;t.:-. -
IL04',-:•-'*.". ;:. -: "6- Expiration: 06/15/204
P.O.BOX 52
:. •:"......i.r,...:i% ,.•''
WEST DENNIS,MA 02670
---------.________-
-,%,.,.:......-.:::::::{'•:;1.:...,..:-;. (.--...';',' ------.______________-
..,:......... :::-.:..:.....-."-;,:-'
... . - Update Address end Return Card.
SCA I 0 20M-05/17
_____. - ........
..9:4 givw,floweewer/14?...aa.,..ticisceraiev:0
•Office of Consumer Affairs a Business Regulation
: .
HOME IMPROVEMENT CONTRACTOR
Registration valid for Individual use only
TYPE:Individual
before the expiration date. If found return to:ReatsttfQfl
fairslign Office of Consumer Affairs and Business Regulation
Om .:•. ,-:-, 06/15/2023 ! 1000 Washington Street -Suite 710
MICHAEL MCOA041-;;:---1--------31:74 . Boston,MA.02;i1fr
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I/,.'!, / if /
MICHAEL F.MC t 7:-. ..4'ig
6 RANGLEY LN. ";ii,..,.. ..- S40,71.0(4/Le.,04. -
SOUTH DENNIS,MA. 021360.
;,./ Not Ind out signature
Undersecretary /*/
g..
Commonwealth of Massachusetts
BUILDING PERFORMANCE INSTITUTE, INC.
Division of Professional Licensure
Board of Building Regulations and Standards
107 Hermes Road,Suite 210
Co nsq011464%)irrisor
Matta,NY 12020 ..:
(877)274-1274
CS-058633 0' --,7t*..7' . spires:04/10/20
At www.bpi.org
MiCHAEL J fte,C:=--rl •r1,-',''1; t; .''''':,''''''- ' - ';',;`.
, I',.g:'-*
PO BOX 62 iA '-;3',„1"4:;!...,
WEST DENNISyMk• ,'-,41:* - . ' .: - • --'.
6 P r P t :
. ..e.s.-;
c woi rih Michael.: 7_:". McCarthy
BPI IDP:5023246
: ' --'''.- ,-- ::-'''..: - :.:•0::r. , r7 '.1-1:....:;7:1Cli
Commissioner 0•‘ e. K. Wemato;,...
, :-, " (SEE REVERSE SIDE FOR DESIGNAIIONS AND EXPIRATION DATES)
Ateheit McCarthy
PO Box 52
VVest DennisMA 02 670
.. I
)•)- 3 P--) cc c.r- fLX e_ sp-)c, ( . 60 r,.1
The Commonwealth of Massachusetts
1►_ ,M=!1, •
Department of Industrial Accidents
__ 1 Congress Street, Suite 100
.7,:(= � 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 Please Print Lesibly
Mtke McCarthy.CDustraaa:tiUII
Name(Business/Organization/Individual): PO BOx 52
Address: West Dennis, MA 02670
Cell (50 - 4 •
City/State/Zip: . ,t CSL-58CFUne IIC-169393
Are you an employer?Check the appropriate box: Type of project(required):
1.1:114m a employer with S.- employees(full and/or part-time).* 7. O New construction
2.0 I am a sole proprietor or partnership and have no employees working for me in 8. El Remodeling
any capacity.[No workers'comp.insurance required.]
3.0I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. Demolition
10 Q Building addition
4.❑I 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.
12.0 Plumbing repairs or additions
5. 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.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other
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.
: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.
Insurance Company Name: AA4 v�...c I kick;(t 4-/ + }-%it 1►nC
Policy#or Self-ins.Lic.#: V te, W C D.313 9 g Expiration Date: ialis- ) 2,
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 cerliify r e i and penalties of perjury that the iLnformation provided above is true and correct
Signature: Date:
Phone l: q 01() O '
-Official use only. Do not write in this area,to be completed by city or town official
Cityor 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#: