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Home My WebLink AboutBLD-93-596 /.^� o, TOWN OF YARMOUTH •, MAileTTACM[ 5 �r :Lana �' Application for a Permit to Build No. 09'‘' 'ilPUPON FINAL APPROVAL 6 ° M P -0 /1 ' ' LOT6 O FEE MUST ACCOMPANY THIS APPLICATION. Lr :: DATE. 1 0 19 e The undersigned hereby applies for a permit to build-' F JaNa according to the following specificationsti � ' ; 1. Name of property ownerCfAgCfS (%LLL�$So. Tel. Soni` 540 Address A-L-A v T Sr IA-74—LPO L- 2.Name of Architect(if any) • Tel. 3. Name of builder PA-uh1O /DELLFT/OZ Address // V.ANSQnr Ra Prq 4. License No. 0071 1/ ' • Tel. g/ R" S3 5. Name of Mason Address 6. License No. y�vSTelr a 7. Construction address - , , 'ess' &i%zn. effi, • v Flood District va 8. Date of subdivision Approval - plain zone Zone 9. Private dwelling 0 Estimated Cost ' : . DO NOT WRITE IN THIS SPACE 10. Multi family 0 / p 0 U t •N... ree2ooIt— Type of room I No. iii —1401lig1QtI£ , 11. Commercial 0 (E 2do F Kitchen 12.Other 0 Dining Rm. 13. No. of stories �� a-0Living Rm. Bed Rm. 14. Foundation — Full 0 Half 0 Crawl 0 Slab ❑ Bath 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 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 i 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.O RELEASEDE. No. e�! RE'-�/C.-e�t�`�1 LOT BY Signature �]� �. PLANNING BOARD Address" /("�K- -�'� �29 ).cr''4 ' ' )- Date /03py� JJl TOWN OF YARMOUTH BUILDING DEPARTMENT . • -'-• • CONSTRUCTION SUPERVISOR FORM PLEASE PRINT: • JOB LOCATION: 7 • (? SS ,�( Vr 1' b • NUMBER ' • • . STREET VILLAGE OWNER OF PROPERTY: ' /: R4_./s(C((S �O^G L!4-Ssa t� �+ , CONSTRUCTION SUPERVISOR: �Dr�4 cJ 'r[ f) /&LL rrf f 06? 11 ( g! 6-6 NAME LICENSE NO. PHONE NO. . . ADDRESS: LICENSED DESIGNEE: (IF OTHER.THAN SUPERVISOR) NAME . LICENSE 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, RESOVAL 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 DE"SOLITION AS REGULATED BY SECTION 109.1.1.OF THE CODE AND THESE RULES AND REGULATIONS. IN THE EVENT THAT SUCH LICENSEE IS NO LONGER SUPERVISING SAID PERSONS, THE WORK SHALL IMMEDIATELY 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 CC:1- STRUCTION SUPERVISORS IN ACCORDANCE WITH SECTION 109.1.1 OF THE STATE BUILDING CODE. I UNDERSTAN: THE CONSTRUCTION INSPECTION PROCEDURES AND THE SPECIFIC INSPECTION AS CALLED FOR BY THE BUILDING OFFICIAL. , INSURANCE COVERAGE: .• , I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGLth.152' Yes ❑ No ❑ If you have checked ves, please indicate the type c average by checking the ap-;rcpriate box. . A liability insurance pciicy 0 Other type of :.idemnity 0 Bond 0 • OWNER'S INSURANCE WAIVER: I am aware that the ucensee does not have the insurance coverage required by Chap a 1 2 of the Maas: rat La s, a that my signature on tn:s permit application waives this requirerrec_ • Check one: . ((( //( -P OwnerJ Agent ❑ • Signature 01 Owner or Owners Agent • SIGNATURE: BUILDING OFFICIAL APPROVAL: ~ . 1 • %--- . Suggeste -- 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.142A requires that the"reconstruction,alteration,renovation.repair.modernization.conversion,inprovement,removal.demolition. or construction of an addition to nnv precristing owneroccuoicd building containing at least one but not more than.four dwelling units....or to structures which are adincent to such residence or budding"be done by registered contractors,with certain exceptions,along with other requirements. /� . Type of Work: I?fi g O Cl F Est. Cost Address of Work g- '34r p4-5 S InVf ic) l�p 0 . Owner Name: l icAK C (S cA- 'co Date of Permit Application: 4—U e (O QS 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 IMPROVEMENT WORK DO NOT HAVE ' ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A. - Signed under penalties of perjury: I he eby apply for a permit as the agent of the owner: ��0/43 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 • • L' = COMMONWEALTH OF MASSACHUSETTS • D -EPARTMENT.MEiv'I.OF LNDUSTItIAL Vhcf, 600 WASHINGTON STREET • • James Campoeu BOSTON, MASSACHUSETTS 02111 comm ss o/ner /� • WORKERS' COMPENSATION INSURANCE AFFIDAVIT 1, G t '1 -LLefrve. 1 (licensee/permittee) • with a principal place of business/residence at: // GU,KS oirra— .1 S y (City/State/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 V.-KC;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 . _ 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 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 status of an employer under the Workers' Compensation Act. I understand that a copy.of this statement will be forwarded to the Department of Industrial Accidents' Office of Insurance for coverage verification and that failure to secure coverage as reouired under Section 25A'of MGL 152 can lead to the imposition 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 S 100.00 a day against me. Signed this ,_O day of A 0— , 19 9 3 Vga21I LiccnseeiPermirret Licensor/Permiror