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HomeMy WebLinkAboutBLD-93-589 e/ LL 2 �fj �; TOWN OF YARMOUTH " MATTACHE 5 Av �,< . 6.% Application for a Permit to Build No. �� UPON FINAL APPROVAL /b' MAP a? LOT _ _ .D /2- a FEE MUST ACCOMPANY THIS APPLICATION. \DATE A - • /93 The undersigned hereby applies for a perm' to build �' according to the following specifications (� �.3 1. Name of property owner ill l /9 C 47` /iTel.-9(f- S7 21 NAddress / 2/r c S' C 0-7-7-- f} v e 2.Name of Architect(if any) Ste' y4,emen, Tel. \3. Name of builder (7 (.J h PR, Address SA-w -e -. 4. License No. Tel. 5. Name of Mason Address 6. License No. Tel. ,/ \-7. Construction address / y a C,SSco� A 1/41e_____SO V,9 R&cq oc�� I/it Flood District 8. Date of subdivision Approval plain zone Zone 9. Private dwelling 0 fr Estimated Cost ` 11" DO NOT WRITE IN THIS SPACE E� ,6 a ,p , Type of room No. 10. Multi family 0 .Z3-� o g �I e�"� !a r ' PEs 11. Commercial 0 aorf-., Kitchen 12. Other 0 --ere-1-eJ 3 OO Dining Rm. ,ofl � Living Rm. 13. No. of stories „C2�a.., 34r'f/ -' f 0 ' a e Bed Rm. 14. Foundation — Full 0 Half 0 Crawl 0 Slab 0 v o Bath 57 15. Materials — Wood 0 Cement 0 Other 0 Deck 16.Type of heat — Oil 0 Gas 0 Electric 0 Other 0 Closed porch 17. Garage — 1 ❑ 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. �C LOT RELEASED BY \Signature ry r I PLANNING BOARD Address / V c eT '� t Ss CCit/-e_.- Date 70 yi`} R nI o eJ 7774 fiChg as COMMONWEALTH OF MASSACHUSETTS �.-- DEPAIC:MEN T OF rNDUSTRIAL ACCIDENTS vck4 -1e 600 WASHINGTON STREET James Campoel; BOSTON, MASSACHUSETTS 02111 • Comm:sstoner WORKERS' COMPENSATION INSURANCE AFFIDAVIT • • (licensee/permittee) • with a principal place of business/residence an / y sco Av © y2AID 0 /' I (CiStare/Zip) • do hereby certify, under the pains and penalties of perjury,that: () I 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. ( ) I am a sole proprietor, general contractor or homeowner(circle one) and have hired the contractors 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 Number • 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 dwelling of not more than three units in which the homeowner also resides or on the grounds appurtenant thereto are not generally considered to be employers under the Workers' Compensation Act(GL C. 152,sect. 1(5)), application by a homeowner for a license or permit may evidence the legal sums of an employer under the Workers' Compensation Act. I understand that a copy of this statement will be forwarded to the Department of industrial Acddenu'Office of Insurance for coverage verification and that failure to secure coverage as required under Section 25A'of MGL 152 can lead to the impoiition of criminal penalties • consisting of a fine of up to 51500.00 and/or imprisonment of up to one year and civil penalties in the form of a Stop Work Order and a fine of 5100.00 a day against me. n Signed this - / Ir .ayof 354 44°C", Q, 19 / 3 LiccasedPer mtrc: Liccnsor/Permi^,or i• • Suggested Affidavit for Home Improvement Contractor Permit Application For orrice Use Only NAME OF CITY/TOWN • Permit No. Date AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application MGL c.1-12A requires that the"reconstruction.alteration.renovation.repair.modernization.conversion.inprovement,removal.demolition. or construction of an addition to any ore-existing owner-occupied building containing at least one but not more that.fou r dwelling units....or to structures which are adjacent to such residence or budding"be done by registered contractors,with certain exceptions,along with other requirements. 1:31-32) Type of Work: / ,eP69Citi 6 "" f Ndo toS Est. Cost c" [ \Address of Work /11�y IJ L<.SSt Co A, ✓v e S'O , Y.9 RAI&07-TT1 •Owner Name: (TE'c`> C�6`P /` ' ' Date of Permit Application: P.93 \ I hereby certify that: Registration is not required for the following reason(s): ' _Work excluded by law Job under 51,000 Bulld' n t owner-occupied \ _ wner 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 as the agent of the owner: Date Contractor Name Registration No. OR: Notwithstanding the above notice, I hereby apply for a permit as c owner of the above property: E-5- 9s 4 - &- � Date OvSelcr Name TOWN OF YAMOUTH BUILDING DEPARTMENT HOMEOWNER LICENSE • a u TION PLEASE PRINT: \DATE 40G 9/ �c�� JOB LOCATION I T Res d 1 / A Yiete4 1,71 ` NUMBER TRE/ET ADDRESS SECTION OF;TOWN \"HOMEOWNER" 6e02Ge [-� ,C`<'4 0-Pr NAME HOME PHONE WORK PHONE PRESENT MAILING ADRESS 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 WI10 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 14110 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 TILE 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. THE UNDERSIGNED "HOMEOWNER" CERTIFIES THAT HE/SHE UNDERSTANDS THE TOWN OF YARMOUTH BUILDING DEPARTMENT MINIMUM INSPECTION PROCEDURES AND REQUIREMENTS AND THAT HE/SHE WILL COMPLY WITH SAID PROCEDURES AND'REQUI' aI TS. / \HOMEOWNER'S SIGNATURELA4-�p�2re�2 c e • ' ` 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 current I'' insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No ❑ If you have checked Vis, 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 net have the insurance coverage required by Chapter 142 cf the Mas General nd that my signature cn this permit application waives this requirement. ✓`iL// Check one: {pa—j Owner Agent ❑ Signature o Omer pf Owner s Agent _ -- —_