BLD-93-582 sit•ae v.. UK 71701 p
- o TOWN OF YARMOUTH oK a' sfr/as
MA ACH 5 i `
CS),k • 0% Application for a Permit to Build No.413
(502
UPON FINAL APPROVAL %CIS•14/ MAP e)cf- XQZ
FEE MUST ACCOMPANY THIS APPLICATION. DATE pC0, 1"
19 93
The undersigned hereby applies for a permit to build f 03
according to the following specifications
1. Name of property owner be 0 G f/or>` Te1.39 Y -v 9 Y
Address - ' Sp rw' 5 tfce.i,va t
2.Name of Architect(if any) Tel.
3. Name of builderOi ,uo 0 ••4-4-%-1/4-°--- Address Address Si isO o uYt - 91, (1)°•"‘"` i
4. License No. 0 07 '/01 Tel. 99 fr 4 1)5- 2
5. Name of Mason _Address
6. License No. 00 7`/7/ Tel.
7. Construction address 7 SPRueiz 9! ' S y/94
Flood District
8. Date of subdivision Approval plain zone C Zone 1P.?,C--
9. Private dwelling 0 Estimated Cost So ' 3 DO NOT WRITE INTHIS
ofroomNo.
10. Multi family 0 �9> /' X7/ `p`-- eK yam ,
11. Commercial 0 3360e- vo- 1_ ON /0/s o!c P?0 Kitchen
12. Other t K I*'-M atx Dining Rm.
/ , Living Rm.
13. No. of stories C. /e of P l D
14. Foundation — Full 0 Half 0 Crawl 0 Slab ' ' r CsO BathRm.
15. Materials — Wood C'Cement 0 Other 0 n Deck I1.'X Li' 1
16. Type of heat — Oil 0 Gas 0 Electric 0 Other ❑ �v �r Closed porch
17. Garage — 1 0 2 ❑ Family Rm.
Sun room
18. Swimming pool - Size Garage
19. Storage shed — Size Shed
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 No. of feet side No. of feet rear
23. Distance from nearest building: Front Ft. side Ft. side Rear
24. Distance back from line or street From rear lot line Side line
25. H.I.C.R. No. /0 6 O et /
�--
LOT RELEASED BY Signature G- 1v
PLANNING BOARD Address 7, 4 es-cds. r 5/
Date /7y e •s 04-- d Z4. / •
7/t4lrf -it/
,
3
FOR LOT "n .
Indicate lecat cn cf garage or accessorf building •
Additions with dashed lines
• Sewerage disposal (cesspool) 0
WeLl 0 .
.• I • 1
I (lot ft. rear) I
4buttar's - � 3 Abutter's
Vame Name
Lot if I Lot if
REAR YARD /
f this is a f)4 -- .,� If this is
orner lot. I ft 4`-'" corner lc
cite in namewrite in
)f street. _ _ ail ' \. •
._ _ -�
name 'of
r •/7n7y /rxr1Tirt.r a ether
I 41 ei..... rp �Z b ° street.
jJr
•
y
SIDE YARD SIDE �'(A:
HOCSE
•
• , .
Q •
SET BACK
-IC ft. •
o I 'c
I
C.
Cr: & frontage)
•
\ / . > S%� it r s/, 291
\ /
\ / (NAME OF STREET)
/ \ ,
I�
� APPLIC.OT: % •"! P BUILDING PERMIT i':
/ADDRESS: - SI'[ TELE.. NO. : DATE FILED:
"BLDG. SITE LOCATION: '11 v- MAPA: a�- LOTH: )( 7 Z
THE FOLLOWING INFORMATION OUTLINES THE PROCEDURAL STEPS REQUIRED TO OBTAIN A PERMIT TO BUILD,
ALTER, OR ADD TO A STRUCTURE WITHIN THE TOWN OF YARMOUTH. THE BUILDING DEPARTMENT WILL DETER-
MINE COMPLIANCE TO THE FOLLOWING (A) ZONING REQUIREMENTS (B) HISTORICAL DISTRICTS (C) FLOOD
PLAINS ZONING. THE BUILDING DEPARTMENT WILL BE RESPONSIBLE FOR ASSISTING THE APPLICANT THOUGH
THE FOLLOWING DEPARTMENTS:
RESIDENTIAL AND/OR COM:IERCIAL BUILDING
•
WATER DEPARTMENT: DETERMINES COMPLIANCE OF WATER AVAILABILITY.
ENGINEERING DEPARTMENT: DETERMINES COMPLIANCE FOR PARKING AND DRAINAGE. '
CONSERVATION COMMISSION: DETERMINES COMPLIANCE TO WETLANDS ACTS, I.E. : IF LOT(S) BORDER ANY
TYPE OF WETLANDS, STREAMS, PONDS, RIVERS, OCEANS, BOGS, BAYS, MARSH
LAND, ETC.
HEALTH. DEPARTMENT: DETERMINES COMPLIANCE TO STATE AND TOWN REGULATIONS, I.E. : REQUIRE-
MENTS FOR SEPTAGE DISPOSAL AND OTHER PUBLIC HEALTH ACTIVITIES.
FIRE DEPARTMENT: DETERMINES COMPLIANCE TO STATE AND TOWN REQUIREMENTS FOR PERSONAL
SAFETY, PROPERTY PROTECTION, I.E. , SMOKE DETECTORS, SPRINKLER SYSTEMS
ETC.
TILE FOLLOWING DEPARTMENTS MUST SIGN OFF, IN THE RESPECTIVE ORDER, PRIOR TO BUILDING INSPECTOR
ISSUING THE REQUIRED BUILDING PERMIT:
REVIEWED BY:
1. WATER DEPARTMENT DATE: N/A:
2. ENGINEERING DEPARTMENT: DATE: N/A:
3. CONSERVATION: DATE: N/A:
4. HEALTH DEPAR'T'MENT DATE: 00;1'3 N/A:
INDU RI AND/OR COMMERCIAL PERMITS
5. WIRING INSPECTOR: DATE: N/A:
G. PLUMBING INSPECTOR: DATE: N/A:
7. FIRE DEPARTMENT: DATE: N/A:
PLEASE NOTE
ALL STUMPS AND/OR BRUSH MUST BE DISPOSED OF AT AN APPROVED SITE. A SIGNED RECEIPT FROM THE
DISPOSAL SITE MUST BE SUBMITTED TO THE BUILDING DEPARTMENT PRIOR TO ISSUANCE OF THE BUILDING
PERMIT.
COMMENTS:
•
BLM/89 /311Y•5?
TOWN OF YAMOUTU
BUILDING DEPARTMENT
HOMEOWNER LICENSE E mrTION
PLEASE PRINT: •p
DATE (/33/J
t<JOB LOCATION 2.9 5'j it.'Ate
NUMBER S .ET ADDRESS SECTION OF;T(O�WN
t IOMEOWNER" pP
69.� .,,_ / 9 S --., i5
NAME HOME dilIONE WORK PHONE
SENT MAILING ADRESS Z2c' , . i
•
CITY OR TOWN STATE ZIP CODE
THE CURRENT EXEMPTION FOR "HOMEOWNER" WAS EXTENDED TO INCLUDE OWNER—OCCUPIED • •
DWELLINGS OF SIX UNITS OR LESS AND TO ALLOW SUCH HOMEOWNERS TO ENGAGE AN IN—
DIVIDUAL FOR HIRE WHO DOES NOT POSSESS A LICENSE, PROVIDED THAT THE OWNER
ACTS AS SUPERVISOR. (STATE BUILDING CODE SECTION 109.1.1)
DEFINITION OF HOMEOWNER:
PERSON(S) WHO OWNS A PARCEL OF LAND ON WHICH HE/SHE RESIDES OR INTENDS TO RE—
SIDE, ON WHICH THERE IS, OR IS INTENDED TO BE A ONE TO SIX FAMILY DWELLING,
ATTACHED OR DETACHED STRUCTURES ACCESSORY,TO SUCH USE AND/OR FARM STRUCTURES.
A PERSON WHO CONSTRUCTS MORE THAN ONE HOME IN A TWO—YEAR PERIOD SHALL NOT BE
CONSIDERED A HOMEOWNER. SUCH "HOMEOWNER" SHALL SUBMIT TO THE BUILDING OFFICIAL,
ON A FORM ACCEPTABLE TO THE BUILDING OFFICIAL, THAT HE/SHE SHALL BE RESPONSIBLE
FOR ALL SUCH WORK PERFORMED UNDER THE BUILDING PERMIT. (SECTION 109.1.1)
THE UNDERSIGNED "HOMEOWNER" ASSUMES RESPONSIBILITY FOR COMPLIANCE WITH THE STATE
BUILDING CODE AND OTHER APPLICABLE CODES, BY—LAWS, RULES AND REGULATIONS.
TUE UNDERSIGNED "HOMEOWNER" CERTIFIES THAT IIE/SUE UNDERSTANDS THE TOWN OF YARMOUTH
BUILDING DEPARTMENT MINIMUM INSPECTION PROCEDURES AND REQUIREMENTS AND THAT HE/SHE
WILL COMPLY WITH SAID PROCED S AND REQUIREMENTS.
VIIOMEOWNER'S SIGNATURE e-- C-P.-era
APPROVAL OF BUILDING OFFICIAL
NOTE: THREE FAMILY DWELLINGS 35,000 CUBIC FEET, OR LARGER, WILL BE REQUIRED
TO COMPLY WITH STATE BUILDING CODE SECTION 127.0, CONSTRUCTION CONTROL.
INSURANCE COVERAGE:
I have a curr nt liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes No ❑
If you have
it
yes, please indicate the type coverage by checking the appropriate box.
A liability Insurance policy 0 Other type of indemnity 0 Bond 0
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by
Chapter 142 he Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one: •
(� 4Owner Agent ❑
. Signature of Owner or Owner s Agent _ _ --
•
-R `� COMMONWEALTH OF MASSACHUSETTS
. t ----DEPAR I M NT OF INDUSTRIAL ACCIDENTS .
• _ _ 600 WASHINGTON STREET
James e Canvpei; BOSTON, MASSACHUSbi IS 02111 •
cor.,m:sooner • WORKERS' COMPENSATION INSURANCE AFFIDAVIT •
1/ ,mia^ tn b— p
Qine) A
(licensee/pere)
• with a principal place of business/residence an -
"2-f? 5.2r— , , ,
. •
(City/State/Zip)
do hereby certify, under the pains and penalties of perjury, that: - .. . _ .. __. _. __ _
[3 1 am an employer providing the following workers' compensation coverage for my employees working on this
job.
•
Insurance Company Policy Number
I am a sole proprietor and have no one working for me.
[ ) 1 am a sole proprietor, gener.J contractockr homeoµ Er (circle one) and have hired the ccn:raaors listed below•
who have the following workers' compensation insurana politic:
Name of Contractor Insurance Company/Policy Number
•
Name of Contractor Insurance Company/Policy Number
• Name of Contractor Insurance Company/Policy Numb::
yI 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 2
dwelling of not more than three units in .vice the homeowner also resides or on the grounds appurtenant thereto are not centrally
considered to be employers undrr the Workers' Compensation Act(GL C. 152.sec.. 1(5)), application by a homcnwner for a license
or permit may evidence the legal status of an employer under the Zoricers' Compensation Act.
•
1 understand that : copy of his statement will be forwarded to the Department of Industrial Acddenu' Office of Insu:.nd for coverage
vtritic::an and that. f:iiurc to se:prc cpvcmgc as rccuircd under Se moa 25A'oi MM. 152 can lead to :. : i^aosi:ipn of criminal penJtie:
consisting of: fine of up to $1500.00 and.'or imprisonment of up to one yeas and dvii penalties Li the form of:St:: ran Order and a
fine of 5100.00 a d:v again.::r.._.
•
• aen day oftar"z , 19 P .
r ;� // /
Suggested Affidavit for Home Improvement Contractor Permit Application
For Office Use Only NAME OF CITY/I'OWN
Permit No.
Date -
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
MGL e.142A requires that the"reconst ru et ion.alteration.renovation.repair.modernization.conversion.inprovement.removal.demolition.
or construction of an addition to any prenisnnz owner-occupied huddinzsontamme at least one hut not more than four dwelling units....or
to structures which are adjacent to such residence or building"be done by registered contractors.with certain aceptions,along with other
• requirements.
Type of Work: .64 ` C Est. Ince&&i c.c.--
Address
c.-Address of Work 4-14 � Ste?
Owner Name: 6.1„. '7iv'.- •
Date of Permit Application:
•
I hereby 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 IMPROVEMENTWORK 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 as the agent of the owner:
�
9/,g 92 44: 4 h r.� //I 6 on
DSte Contractor Name Registration No.
OR: •Notwithstanding the asbove nail" r! licr apppppp • fora r it as the owner of the above property:
/
!� • /f� tXl
Date / Ov.ner Na ,c --
— _ /r,rir Siva cmt ... — —
4 11—
ca-41-41-.1A-4 tar tZtenrit jr)Clui__IL, L-A 04,
14
4 --- - l T L LI � ( � _ Y`
-- - r
I, rt „�r,0s
s