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Home My WebLink AboutBLD-93-609 I /.;F:Ygii . a (( „ad ;1/tin M.. b o . TOWN OF YARMOUTH or-r,_, g/43/`t"3 Di �, i 1 iCy, - %,,ttr::.01Yg% Application for a Permit to Build No. UPON FINAL APPROVAL 0, Q' iaai3 MAP pt ( �LL,,O//T /1--/LC FEE MUST ACCOMPANY THIS APPLICATION. DATE n / 19 93 The undersigned hereby applies for a permit to build �3/ 9 3 according to the following specifi .tions 603. 67L-2 /g tiC Name of property owner / _ . . a . Tel. Address S ,. cuc4 _i !. /,alit A s .sr • 2.Name of Architect(if any) Tel. Name of builder mwint✓Z Address 22 WiZ/ .4) ,c) .S',,eru' 4. License No. Tel. 5. Name of Mason Address 6. License No. Tel. /7. Construction address -Z7 j.J,V,6'0 2J) S 264yefrarc z; Flood District R_etre8. Date of subdivision Approval plain zone }) Zone 9. Private dwelling 0 Estimated Cost _ADO NOT WRITE IN THIS SPACE �� low/ Sur& Type of room No. 10. Multi family 0 9-X/0 11. Commercial 0 �� ,%r A 9XI Kitchen 12. Other J„zy/ ?, Dining Rm. 13. No. of stories Living Rm. da, , a J Bed Rm. 14. Foundation — Full ❑ Half 0 Crawl 0 Slab ❑ Bath 1 �,/ 15. Materials — Wood 0 Cement 0 Other 0 / r 0 v Deck 16.Type of heat — Oil 0 Gas 0 Electri /❑ Other 0 Closed porch 17. Garage — 1 ❑ 2 ❑ Family Rm. Sun room 18. Swimming pool - Size Garage 19. Storage shed — Size 700 Thk- FITShed crX ics : , 20. Stove — Wood 0 Coal ❑ I Poiti, 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 2a 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 RE E. No. 4(g LOT RELEASED BY / ignature .-�. T PLANNING BOARD ✓ Address .Sit- Sex45,�a'rr - Date Ai LA c _-f AY( 0 30 3 i TOWN OF YAMOUTH • • - " BUILDING DEPARTMENT - 1O EOWNER LICENSE EXEMPTION PLEASE PRINT: DATE Pj(743 [/(B LOCATION a ) .{f`mac..., ,d/ s./Gr--[4.s p-cc�(� NUMBER U00 STREET ADDRESS SECTION OF;TOWN LPRO IEOWNER" FrEP r��CziC� ea3^X 72 2Gz ted • • ES zo 7x^E0/6 3 NAME -.= HOME PHONE WORK PHONE • r„ -PRESENT MAILING ADRESS 14-. A a CJS e' e J>e • _- - .- _ • /414C7e Sr /7" • �/ 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/SITE 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 TUE BUILDING OFFICIAL, ON A FORM ACCEPTABLE TO THE BUILDING OFFICIAL, THAT HE/SUE 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 OMER APPLICABLE CODES, BY-LAWS, RULES AND REGULATIONS. THE UNDERSIGNED "HOMEOWNER" CERTIFIES THAT HE/SHE UNDERSTANDS TUE TOWN OF YARMOUTH BUILDING DEPARTMENT MINIMUM INSPECTION PROCEDURES AND REQUIREMENTS AND THAT BE/SHE ' WILL COMPLY WITH SAID PROCED S AND REQUI• aINTS. VIOMEOWNER'S SIGNATURE _el _ELM • 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 liability 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 not have the insurance coverage required by Chapter 42 of the Mass. General Laws, and that my signature cn this permit application waives this requirement. � � C eck one: Owner Agent 0 Si;. a;:re ct Owner c Owner s Agent PLOT PLAN • - FOR LOT # ' Indicate location of garage or accessory building Additions with dashed lines Sewerage disposal (cesspool) a _ weir 0 • I (lot ft. rear) Abuttor's //. _ Abutto Name ! —// 5 Name Lot # ' 111 I Lot # REAR YARD) & If this is a • to f If thi corner lot, 1 ft. corn write in name • write of street. name ' ' � a ..other" 'eam gyp• aa)i stree ro • • SIDE YARD . SIDE YARD • HOUSE 0 FT. 0 . . 0 FT0 • �.� . . ,, . SET BACK • o I ft I • (lot ft. frontage) . • / 1 97w,Z,c,) prb S , /` \. // (NAME OF STREET) < / \ -Information a/ Supplied by `/i dG_rQ'' " • 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 c.142A requires that the"reconstruction.alteration.renovation,repair.modernization.conversion.inprovemen t,removal.demolition. or construction of an addition to any pre-existing owner-occupicd building containing at least one but not more than,four dwelling unus....or • to structures which arc adjacent to such residence or building"be done by registered contractors,with certain acceptions,along with other requirements. ------ss Z_ �� Type of Work: /m /3 Est. Cost 2-73tfi t &dress of Work ecl 2 N ,, '/'f) pt7 4.----Owner Name: 142J2. 1EE • R i2oD(eic k 'Date of Permit Applicatio j(// le< k 3' I hereby certify that: (r 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 as the agent of the owner: Date Contractor Name Registration No. . OR: Notwithstanding the above notice /r thy apply for a ermit as the owner of the above property: Dale Owner Name -S Y=- _ COMMONWEALTH OF MASSACHUSETTS g =__ •= E -'2tet • DErAR:MErT OF INDUSTRIAL ACCIDENTS ' 600 WASHINGTON STREET • James.; Gamooeu BOSTON, MASSACHUSETTS 02111 . con n:ss�one WORKERS' COMPENSATION INSURANCE AFFIDAVIT • j", ,0 (licensee/permiflee) with a principal/place of business/residence an n //✓l p r ( 2 (City/Sure/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. H] I am a sole proprietor,general contractor o (circle one)and have hired the contractors listed below who have the following workers' compensation i •• . - ••licies: ••••-••••.----. -.. ;:f. - • -- Name of Contractor . Insurance Company/Policy Number . . Name of Contractor .. Insurance Company/Policy Number • - . .. �NNaame of Contractor Insurance Company/Policy Number tXJ 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 required under Section 25A'of MGL 152 can lead to the imposition of criminal penalties • consisting of a fine of u• • $1500.00 and/or imprisonment of up to one year and civil penalties in the form of a Stop Work Order and a fine of S100.00 a da . rsttm�e. �( Signed thi , J . P �- day of 41.1e�, 19 ! > Licensee/Permit-re: LiceasoriPermiror