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Home My WebLink AboutBLD-93-599 ' ' ,.Ot.y,944,` Q/' /c$fl $ - o TOWN OF YARMOUTH etc #e fletiis joi4" —yl SAA ,,. I�� `1 1 `'CC.0 "0 ; Application for a Permit to Build No. X197 UPON FINAL APPROVALfr6--- . . MAP cr 0 A51, FEE MUST ACCOMPANY THIS APPLICATION. DATE t� 19 43 The undersigned hereby applies for a permit to build b 111 H5 according to the following specifictions - I IS� 1. Name of property owner i.y- e S t. I Tel. Address .•.1 k • • 2.Name ofArchite if any) Tel. 3. Name of builder M s _IU1r . .r+.• °rairs• . .ress S "IA in'ic-efI ° 1 4. License No. o°5`S135 Tel. !604 6-0CJ S ` cnnis 5. Name of Mason Address 6. License No. Tel. ,, \ 7. Construction address (L?C,11II Q .(12-1) • Clocnna Flood District 8. Date of subdivision Approval plain zone Zone a- Hb 9. Private dwelling 0 Estimated Cost VP' DO NOT WRITE IN THIS SPACE Type of room No. 10. Multi family ❑ /003 g-b-�3 f d :(1-6 11. Commercial ❑ G' �O �� 6/�3 Kitchen 12. Other o Dining Rm. 13. No. of stories pint-0 Living Rm. eczzrc bt°cic Bed Rm. 14. Foundation — Full 0 Half 0 Crawl 0 Slab 0 — / 0 ad Bath 15. Materials — Wood 0 Cement 0 Other 0 /0-; gip, 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 g) (0 Shed g '//() J 2a 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 1 0 No. of feet side g No. of feet rear 10 23. Distance from nearest building: Front Ft. side Ft. side Rear 24. Distance back 3 from "I line oxstr n ear lot line Si a line 25. H.I.C.R. No. 0 LOT RELEASED BY Signat e 7 fia PLANNING BOARD Address Date BUILDING DEPARTMENT •• CONSTRUCTION SUPERVISOR FORM PLEASE PRINT: '• • 1L4' y�/ JOB LOCATION: • '� RQ- �C1 5. • Ot ► ICJ0$1 • NUMBS� •^ ^ ,� STREET: . . VILLAGE • • OWNER OF PROPERTY: ' I r W� c �).�k I �9� CONSTRUCTION SUPERVISOR: c r r l r / . • .l`C'C cz O4Stt5 • /C�iSLO . �. NAME LICENSE NO. PHONE NO. ADDRESS: I�^ td:k Vll�<��"V I ► (� ' non. ,ni5 . 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, REMOVAL OR DEMOLITION INVOLVING THE STRUCTURAL ELE4ENTS 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 BE 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 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 :ICENSING CCN STRUCTION SUPERVISORS IN ACCORDANCE :LITH 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 OVERAGE: I have a curr liability insurance policy or its substantial equivalent which meets the requirements of MGLth.152 ' Yes ' . No 0 v„s If you have Necked . ,^,:ease inciccte the type c average by checking the a:arc:nate bcx. . •I A liability insurance pc:icy 0 Other type of :.idemnity 0 Bond 0 OW WS INSURANCE WAIVER: I am awa .- that the t censee does rat have the insurance coverage. require: .../ Ch Ater 2 of the Ma's General -• s, a istt my signature cn tr.:s permit ccp:ica:icn waives this requirement `moi - '/ Y g-•• Check one: • • Owner° A ruram Owner cr Owner gent . ' -GNATURE: . BUILDIN OFFICIAL APPROVAL• • • • r ;-21,4..-÷-511-_-- . COMMONWEALTH OF MASSACHUSETTS �_ -- DEPARTMENT- OFINDUSTRIALACCIDENTS ------- r ,L,_ '' 600 WASHINGTON STREET • James J CamooeP BOSTON, MASSACHUSETTS 02111 romn:ss,oner WORKERS' COMPENSATION INSURANCE AFFIDAVIT • I, ?rw Hdv-bor Woe() Pvcdot / Joyuts C .H%b , (licensee/permittee) with a principal place of business/residence at: • )Z0 rprer - t s-eSn ) S . f)P2 nest ,M ` oz666 (City/State/Zip) do hereby certify, under the pains and penalties of perjury, that: _. ..it' am an employer providing the following workers' compensation coverage for my employe:5 working on this job. 1T4 006 C on-73,369 Asa • Insurance Company Policy Number CAA. ( ) I am a sok 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 Numb:: Name of Contractor Insurance Company/Policy Numb:: 0 I am a homeowner performing all the work myself. NOTE_.Please be ante that while homeowners who erplov persoos 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(CL. 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. 1 understand that : copy of this statement will be forwarded to the Department of Industrial Acddents' Office of insp and for coverage vcritic::;on aced that failure to;cure cover_e as recuired under Se don 25A.01 MC- 152 can lead to tae imposition of criminal penalties concisane of: fine of up to $1500.00 ancbr imprisonment of up to one yea:and Sil penalties is the form of:St::rod: Order and a fine of 5100.00 a day against me. —Tr__ .n's da or F3/5 , 19 1 3 • 41/ V—, �1 / I , /iiri PLOT PLAN FOR LOT n Indicate locadcn cf garage or accessory building • Additions with dashed lines Sewerage disposal (cesspool) 0 Well p . I • I . I (lot ft. rear) I Abutter's I V Shed Abuttor's Vame Name Lot If 9 4 Lot # REAR YARD /O8 I this is a If this is :orner lot, 1 ft. corner In .trite in name write in Lf street. I t name *of c • I u other o 0. v sweet. o gystem SID? YARD SLD- Y..1.. HOUSE - , 0 . • SET BACK o I ft. c I C. (s: f`. frontage) \ / /# e / ,'& o a cL \ \ / (NAME OF STREET) , < • / \ `} I � • Suggested Affidavit for Home Improvement Contractor Permit Application For Office Use only NAME OF CITY/TOWN Permit No. Date • AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application MGL e.142A requires that the"reconstruction.alteration.renovation.repair,modernization.conversion.inprovement,removal.demolition. or construction of an addition to any pre-cestinz owneroccumed hmldme containing at least one hut not more than four dwellint units....or to structures which are adjacent to such residence or hwldine"be done by registered contractors,with certain aceptions,along with other • requvements. Tylpe of Work: (onSii V dl onor 6}va -.d/�nnEst. CQstIWO Address of Work I 1 ()Gi n� EA 3 . W t Y IC,� Owner Name: `C r��ka Date of Permit Application: I hereby certify that: Registration is not required for the following reason(s): _Work excluded by law CxJob 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 as the agent of the owner:_ft/4.a ea "22€14072 10937Y 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