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Home My WebLink AboutBLD-93-581 OK Fs) otrf y TOWN OF YARMOUTH • t15149 ,' MAT ACHE 41.1 L5 �, 6c-'i Application for a Permit to Build No. Ey g-3- 3 _ UPON FINAL APPROVAL MAP Z L LOT G13 t FEE MUST ACCOMPANY THIS APPLICATION. DATE G- 3/933 The undersigned hereby applies for a permit to build according to the following specifications .3 � 1. Name of propertyownerr C4-nt$'r2tNt; PiA `ZERvN ot �e' l34�-- v.Zaa:. • Address at E_PREnaYT" g-r: Wr- -r-Ft&D MA 0f ? g' 6 . , 2.Name ofArchitect(ifany) ' ` ' Tel. ' ; 3. Name of builder VI PIE. Wrrob Address 120 Cefrr tl)ES? Pte' Ku- S&'•N G4.S13C - Tel. 76o=4Soo 4. License No. ' 5. Name of Mason Address ' 6. License No. Tel. " 7. Construction address G 3 L�7%'K J DG'C '.)- °V Flood District 8. Date of subdivision Approval plain zone Zone R„lc 9. Private dwelling 0 Estimated Cost DO NOT WRITE IN THIS SPACE or • Type of room . No. 10. Multi family 0 f,. B39 , 4 �" 11. Commercial .❑ 1 o, D. Kitchen 12. Other Dining Rm. 13. No.of stories • Living Rm. Bed Rm. 14. Foundation — Full 0 Half 0 Crawl 0 Slab 0 0-000 Bath 15. Materials — Wood K Cement 0 Other ❑ Deck 16:Type of heat — Oil ❑ Gas 0 Electric 0 Other❑-, Closed porch _ 17. Garage — 1 ❑ 2 ❑ Family Rm. Sun room 18. Swimming pool - Size . Garage 19. Storage shed — Size 9 X ei Shed g%.8' I" • 20. Stove — Wood 0 Coal 0 Alterations 21. Size of lot: No. of feet front No.of feet rear No. of feet deep . 22. Size of building: No. of feet front ' t No.of feet,side 8 t No. of feet rear B t 23. Distance from nearest building: Front ' Fi 'de ' ` ' '-• 'Ft. side Rear 24. Distance back from line or street -ro year lot line �� Scid line jJ If.1,c.R. /a93'7g rdi / /,%M S'S /' LOT RELEASED BY Signature .tirthili to • �/ • ' • PLANNING BOARD Address -t r � ' ' Date C!1� M A 0 t s' 8// i 1 / ' , I '• FOR LOT fl G ) 3 L- • Indicate locat:cn of garage cr accessory building • Additions with dashed lines Sewerage disposal (cesspool) ED Wel 0 I I (lot ft. rear) 4buttor'sAbuttor's lame Name Lot ifgu -7 Lot q Q REAR YARD ypkEPtHN f this is a 3 S If this ' :orner lot, .ft. corner lc 'trite in namewrite in if sweet. name •of • 1 c ether u 0 a street. u ecJ • j� V 4 SIDE/ YARD SIDE YARD 0 / 1-• r-• HOUSE _ _ _ Q • • • I I - SET BACK acft. 0 I c I -. I (mac a frontage) • \ \ / (NAME OF STREET) / \ ?.....r._. ....:—, h ei€ t g 4 t &11 • BUILDING DEPARTMENT ' CONSTRUCTION SUPERVISOR FORM S - PLEASE PRINT: ' . ' p/�/+� A. C ' / �1 JOB LOCATION: ,3 £o/�-a gg /-'� • c J• 7 i o U • TI NUFIBER2eatST ET VILLAGE • OWNER OF PROPERTY: ' C�Ce/NE ✓1n • ^� ,q CONSTRUCTION SUPERVISOR: /VIES O• I ► L��J V��3S• �' 766-1{S o . NA"ENl. LICENSE NO. ..NO. PHONEtN0. •ADDRESS: . czo 6eFA-- CLJCS ` - S Di iut4 5; r T'. • LICENSED DESIGNEE: ' (IF OTHER,THAN SUPERVISOR) NAMELICENSE NO. 2.15 RESPONSIBILITY OF EACH LICENSE.HOLDER: . . , 2.15.1 THE LICENSE HOLDER SHALL. BE FULLY AND COMPLETELY RESPONSIBLE FOR ALL WORK FOR WHICH HE IS SUPERVISING. HE SHALL BE RESPONSIBLE FOR SEEING THAT ALL WORK IS DONE PURSUANT TO'THE STATE BUILDING CODE AND THE DRAWINGS AS APPROVED BY THE BUILDING OFFICIAL • ' . . 2.15.2 THE LICENSE HOLDER SHALL BE RESPONSIBLE TO SUPERVISE THE CONSTRUCTION, RECONSTRUCTION, ALTERATION, REPAIR, REMOVAL OR DEMOLITION INVOLVING THE STRUCTURAL ELEMENTS OF BUILDING AND STRUCTURES ONLY PURSUANT TO THE STATE BUILDING CODE AND ALL OTHER APPLICABLE LAWS OF THE COMMONWEALTH, EVEN THOUGH HE, THE LICENSE HOLDER, IS NOT THE PERMIT HOLDER BUT ONLY A SUB– CONTRACTOR OR CONTRACTOR TO THE PERMIT HOLDER. 2. 15.3 THE LICENSE HOLDER SHALL IMMEDIATELY NOTIFY THE BUILDING OFFICIAL IN WRITING OF THE DISCOVERY OF ANY VIOLATIONS WHICH ARE COVERED BY THE BUILDING PERMIT. 2.15.4 ANY LICENSEE WHO SHALL WILLFULLY VIOLATE SUBSECTIONS 2.15.1, 2.15.2 OR 2.15.3 OR ANY OTHER SECTION OF THESE RULES AND REGULATIONS AND ANY PROCEDURES, AS AMENDED, SHALL 3E SUBJECT TO REVOCATION OR SUSPENSION OF LICENSE BY THE BOARD. 2.16. ALL BUILDING PERMIT APPLICATIONS SHALL CONTAIN THE NAME, SIGNATURE AND LICENSE NUMBER OF THE CONSTRUCTION SUPERVISOR WHO IS TO SUPERVISE THOSE PERSONS ENGAGED IN CONSTRUCTION, RECON– STRUCTION, ALTERATION, REPAIR, REMOVAL OF DEMOLITION AS REGULATED BY SECTION 109.1.: OF THE CODE AND THESE RULES AND REGULATIONS. IN THE. EVENT THAT SUCH LICENSEE IS NO LONGER SUPERVISING SAID PERSONS, THE WORK SHALL Ir. EDIATELY CEASE UNTIL A SUCCESSOR LICENSE HOLDER IS SUBSTITUTED ON THE RECORDS OF THE BUILDING DEPARTMENT. I HAVE READ AND UNDERSTAND MY RESPONSIBILITIES UNDER THE RULES AND REGULATIONS ,FOR LICENSING CCI STRUCTION SUPERVISORS IN ACCORDANCE WITH SECTION 109.1.1 OF THE STATE BUILDING CODE. I UNDERST!_: THE CONSTRUCTION INSPECTION PROCEDURES AND THE SPECIFIC INSPECTION AS CALLED FOR BY THE BUILDING OFFICIAL. INSURANCE COVERAGE: . I have a carr nt liability insurance pclicy or its substantial equivalent which meets the requirements cf MGLth.152 Yes . No 0 If you have e. ed vme. pease incic:te the type c average by checking the apercariate bcx. • 1 Allah • 'nsurance pc:icyk Other type of :.idemnity 0 Band 0 •WNEt 5 INSURANCE WAIVER: I m awa that the licensee dace rct have the insurance coverage require- :y C`3 152 f the to G ner ws an my signature on t`:s permit :=p,ica:!ca war:es this requirement. Oir, /'�J// 1/ /) Check one: • e G( Owners Agen,w Ce r lir caner '-gent SIGNATURE: . BUILDING `OFFICIAL APPROVAL• . • • �' COMMONWEALTH OF MASSACHUSETTS . DEPARTMENT OF INDUSTRIAL ACCIDENTS ? ' 600 WASHINGTON STREET • • James Camvoee BOSTON, MASSACHUSETTS 02111 • ronintsstone' • = WORKERS' COMPENSATION INSURANCE AFFIDAVIT • I, Jr1 0 (11 c(,1nt+- (Iiccnsee/permincc) • with a principal place of business/residence an • (City/Sutc/Zip) do hereby certify, under the pains and penalties of perjury, that: IJJ�1 am an employer providing the following workers' compensation coverage for my employees working on this job. Ag-77V 4 0o6 C ooz33496c8 CPA ' . Insurance Company Policy Number [ ) I am a sole proprietor and have no one working for me. t 1 am a sole proprietor, general contractor or homeowner (circle one) and have hired the cont Fetors listed below who have the following workers' compensation insurance policies: Name of Contractor Insurance Company/Policy Number Name of Contractor Insurance Company/Policy Number Name of Contractor Insurance Company/Policy Numb:: o I am a homeowner performing all the work myself. NOTE.Please be aware that while homeowners who employ persons to do maintenance,construction or repair work on a dweiiinz of not more than three units in which the homeowner also resides or on the grounds appurtenant thereto art not generally considered to be employers under the Workers' Compensation Act(GL C. 152.sect. 1(5)).application by a homeowner fora license or permit may evidence the Jeal SUNS of an employer under the Workers' Compensation Act. I understand that : copy of this statement will be forwarded to the Department of Industrial Accidents' Office of Insutanc for coverage vetrijk non and that Failure to iecure coverage as required under Section 25A'of MGL 152 can lead to the imposition of criminal penalties consis:ng of:sine of up to 51500.00 angor imprisonment of up to one year and civil penalties in the form of a Star Work Order and a fine of 5100.00 a day ar;ains:me. Signed �� t day of OU941Sr 19 97-e, SAA LicerrPerrn...__ L.a_nso.rPe _.. " y• Suggested Affidavit for Home Improvement Contractor Permit Application For orrice Use Only , FAME OF CITY/TOWN Permit No. t/(U.rrnov n� Dale J AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application MGL c.142A requires that the"reconstruction,alteration,renovation.repair,modernization.conversion.inprovement,removal,demolition. or construction of an addition to any pre-ccisting owner-occupied budding contain ing at least one hut not more than four dwellinz units....or to structures which are adjacent to such residence or building"be done by registered contractors,with certain accpttons,along with other requirements. C Type of Work: (Oil$7 y,/e .�'+\AL Est. Cost. c—adress of Work a t- 1 e ��y '` OR'1O Owner Name: C j U`//VG ,d ate of Permit Application: 01275 Vhereby certify that: Registration is not required for the following reason(s): _Work excluded by law _Job under 51,000 _Building not owner-occupied _Owner pulling own permit _Other (specify) Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ' ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A. Signed under penalties of perjury: I hereby apply for a permit�a he agent of the owner: /A/ iiineene Date Contractor Name Registration No. OR: Notwithstanding the above notice, I hereby apply for a permit as the owner of the above property: Date Owner Name