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$ ; 0 TOWN OF YARMOUTH aKFC0 016(43
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He6,,"4;ACHE '0 J Application for a Permit t5 4o Build No. C,ia
UPON FINAL APPROVAL 0 T-i 'J MAP /4 LOT 2 3
p /
FEE MUST ACCOMPANY THIS APPLICATION. DATE 19 -93
The undersigned hereby applies for a permit to build y /3193
according to the following specifications fe cr
1. Name of property owner -PA 4'1ft ‘ Cot,/ iitC Tel. 77f- 6/Co
Address It F4tA-Kuw JT f=f west,o ow
2.Name ofArchitect(ifany) /,3 Msr+,t __ if61-A4rii- Tel.
3. Name of builder 2/\ NIii /Z 4 Address MO iffelAr Mgre.i.4 e0• S ntUuaS
4. License No. DYC/3SC Tel. 760-4/S 0 •
5. Name of Mason _Address
6. License No. Tel.
7. Construction address - ft (;/' 'K(IA— if e)`f v&, X414 PVT)9
Flood �/ District
8. Date of subdivision Approval plain zone /� Zone WY-1'
9. Private dwelling 0 Estimated Cost t• P t DO NOT WRITE IN THIS SPACE
�,a .� • e/d/o,00 ��L/ys Type of room No.
10. Multi family ❑ /000 o
11. Commercial ❑ ' Kitchen
12. Other ❑ �0 ren Dining Rm.
13. No. of stories — ( o r d c) bleed Living Rm.
Bed Rm.
14. Foundation — Full 0 Half 0 Crawl 0 Slab 0 Bath
/er 00
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 8 x i 6 Shed' MA0 t
20.Stove — Wood 0 Coal ❑ 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 /6 r No. of feet side 8 / No. of feet rear /0 /
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. /013�9 tJ4'i EJ D, /AC 644 tit)
LOT RELEASED BY Signature L/"""1 2,
PLANNING BOARD Address `r` PMMIctrA,"4" et`
Date WI yA4M 0urf/ X24. 041 7)
• PLOT LAN ! 9
FOR LOT tri
Indicate lccatihn cf garage or accessory building •
Additions with dashed lines
Sewerage disposal (cesspool) e
Well 21
(lot ft. rear) I
— — — — to . - - - —
kbuttor's I a Abuttor's
lame a 6"fir Name
Lot # Lot #
•
REAR YARD
f this is a d If this
orner lot, 1 ft. c.�/ corner lc
write in name v • write in
• street.
1 name 'of
c I C
other
•
-0 a steec.
u
j! •
ud y
SIDE YARD SILT YARD
ROUSE
0 q - -- - - - - .
•Q
SET BACK
1.1
o ft.
(]I` f` frontage)
•
\ S� F'MMccc& 'I f;Yre-)(oN
\ /
\ / (NAME OF STREET)
/
/ \ ,
:. - TOWN OF ,YARMOUTH i '
BUILDING DEPARTMENT • -
' _ - '- CONSTRUCTION SUPERVISOR FORM
PLEASE PRINT: ,/
JOB LOCATION: S_(n ' f/2EJ✓KL-/)/ S r, /5 X , w y , •
NUMBER • . STREET • VILLAGE
OWNER OF PROPERTY: ' oL3 ea • Sm�'-)7s'6 /(00 • l/7- /V!- •
CONSTRUCTION SUPERVISOR: 77/4Jyt c A Hc4MTN • � oyc%StrT 7.6o Y,f2,0
NAME LICENSE NO. PHONE NO.
•
ADDRESS: •/2-p 4.47:077,0�S/�{.t�� • • �',, •, 7/en/1/S1 ////Q . 44.6.
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 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 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 CC:T-
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 v_s, please indicate the type cwerage by checking the ap:rcpriate box. •
•
A liability insurance policy 0 Other type of :.idemnity 0 8cnd 0
•
OWNER'S INSURANCE WAIVER: I am aware that the rcensee does rot have the insurance coverage required by
Chapter 152 of the Mass. General Laws, anc that my signature en t:t:s perms tzr.licztion waives this requirement
. • Check one:
• Owner❑ Agent 0 •
Signature m Owner orOwners Agent •
SIGNATURE:� ,jam, BUILDING OFFICIAL APPROVAL: •
•
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 a 142A requires that the"reconstruction.alteration.renovation.rennin modernization.conversion.inprovement.removal.demolition.
or construction of an addition to anv pretesting owner.o curved budding containing at least one hut not more than four dwelling units....or
to structures which are adjacent to such residence or pudding"be done by registered contractors,with certain exceptions,along with other
• requirements.
Type of Work: (ors-/ra !J e� n/Shad at. Cost ZOO,
Address of Work tic FAA-(«/ ^- .1'j e Jet
Owner Name: Ii9N((C L 6.OL04er&C
Date of Permit Application: /99
I hereby certify that:
Registration is not required for the following reason(s): •
_Work excluded by law
_Job under 51,000
_Building not owncr•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. I42A.
Signed under penalties of perjury:
I hereby apply for a permit as the agent of the owner:
I�QQss J/fmes D. /Y1 eG / /693 ?y
Dat Contractor Name Registration No.
OR:
Notwithstanding the above notice. I hereby apply for a permit as the owner of the above property:
trp/9) . 1,6is•,.i at /1-667
Date Owner Name
' - COMMONWEALTH OF MASSACHUSETTS
•
DEPARTMENT OF INDUSTRIAL ACCIDENTS • -
-- -• ;1600 WASHINGTON STREET -
James J Carapace BOSTON, MASSACHUSETTS 02111
rorrn.sslonet •
WORKERS' COMPENSATION INSURANCE AFFIDAVIT •
2?4J in /IOW& &6
(licensee/perrninec)
• with a principal place of business/residence ar. •.
- /20 G,' — tit ai ,7. LS; �P . .
(Ciry/SratdZip)
do hereby certify, undcr the pains and penalties of perjury, that:
,pppuffff ,..,.
lam an employer providing the following workers' compensation coverage for my employees working on this
Oth7a 666 C O2 336965-g
Insurance Company Policy Number
[ ) lam a sole proprietor and have no one working for me.
( ) 1 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::
o 1 am a homeowner performing all the work myself.
NOTE••.Please be aware that while homeowners woo employ persons to do maintenance. ecastrucion or repair work on 2
dwciiin: of not more than three units io wvita the homeowner aha resides or on the grounds appuneaaat thereto art not centrally
considered to be erpioyers under the Workers' Compensation Act(CL C. 152.sea- 1(5)). application by a boreowoe:for license •
Of permit may evidence the legal SLIMS of an employer under the Workers' Compensation Act.
I undcrt::nd that : copy of t:Js statemen:will be forwarded to the .Department of industrial Aeddena' Orrice of insur.nc for coverage
vcr:ieaaon and the: failure to secure cove.-4: as required under Sc_oa 25A'of MCI- 152 can lead to :..e impo:iaca of criminal penalties
ccnsispnc of: fine of up to 51500.00 anc'or imprisonment of un to one year and dtv penaides Li the form of:Sm- Work Order and a
fine o[5100.00 a day a£air.s: mC.e./4— /��i
Sic J /1 d-.: of divict , 19 93 • •