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Home My WebLink AboutBLD-93-612 • - - ,,4�4: , v% TOWN OF YARMOUTH Etc Fe`' 1 . w!I� �C}� MATTACtlC S L(°r V:k.. .,,a•5 .% Application fora Permit to Build No. �� UPON FINAL APPROVAL ed I•/ � lb M P lbs LOT S 9 . FEE MUST ACCOMPANY THIS APPLICATION. DATE gl/ 3 1/9 /3137 The undersigned hereby applies for a permit to build /9 lam-' according to the following spe •' 'cations 3 1. Name of property owner Att4,,Rn,f� AMA- 7'4CZ 3r -3 Address 01 IMMVO 51 • N, , � aimAA r 2.Name of Architect(if any) \ Tel. a Name of builder Janlf't\nA, \ M ( Address ad 14-71Q64' a `foie-r 4. License No. O'AM S 10 Tel. 38 S 26 6 7 5. Name of Mason Address 6. License No. Tel. , 7. Construction address r Q° A �' F`" `\MA 104- �'� lood District R sip 8. Date of subdivision Approval plain zone C. Zone 9. Private dwelling 0 Estimated Cost DO NOT WRITE IN THIS SPACE Type of room No. 10. Multi family 0 7-1 coo -'s R n�P_S / Sle `c) qq ' 11. Commercial 0 Q nc 4 a-� Kitch n n pr'(�e ��02 12. Other 0 kat ?I'CA n �� Dining Rm. V2k ) c Living Rm. 13. No. of stories Bed Rm. 14. Foundation — Full 0 Half 0 Crawl 0 Slab 0 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 ❑ 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 3 0 No. of feet side ZC, No. of feet rear 3 tt 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. 04-/S7f /plaid LOT RELEASED BY Signature A PLANNING BOARD Addres-/ i b fro-IQ lick... 47 Date 1 in!l IAA Oink-lir_ `. TOWN OF .YARMOUTH . BUILDING DEPARTMENT • CONSTRUCTION SUPERVISOR FORM PLEASE PRINT: • • qr �y . {.�., . rt—. JOB LOCATION: I ' ' W� 31 ' i � t ` N ER\ � An /� S ET VILLAGE OWNER OF PROPERTY: - \,A&\DAAA C'R�144/9N ' CONSTRUCTION SUPERVISOR: .CS--64A7 LMJ —PP/CC O S vg-)O ' • 9 3_C- �6 . NAME LICENSE NO. �• PHONE NO. . ADDRESS: • �n . .. J h� Gw : xI�C�1T VI Jrc `:r I1 ,; • . 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 LA«S 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 I}2IEDIATELY 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 CCI- 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 curr liability insurance policy or its substantial equivalent which meets the requirements of MGLth.152 Ye •. No ❑ . If you have checked vis, please indicate the type c average by checking the aptrcpriate box. A . A liability insurance peaty ❑ Other type of :.idemnity❑ eand 0 OWNE 'S INSURANC— fI am aware that the ucensee deer rot have the Insurance coverage requirec :y • Chao ‘; 152 of ane that my signature cn the it perm :cpticaticn wanes this requireniert. ' qv s 1 1 1 • Check one: , • �— Owner° Agent ❑ sigl.cure of Owner or O,.ner s Ager ' SIGNATURE: . BUILDING OFFICIAL APPROVAL: ' 1I ^ � _ t COMMONWEALTH OF MASSACHUSETTS • -`��' DEPAICMENTOFINDUSTRIALACCIDENTS � 600 WASHINGTON STREET • James CampbellBOSTON, MASSACHUSETTS 02111 • comm ss over WORKERS' COMPENSATION INSURANCE AFFIDAVIT • I, ` IDA kk \t\\ k S (licensee/permittee) • with a principal place of business/residen at: • C (City/S to/Zip) 0 do hereby certify, under the pains and penalties of perjury.that: . () 1 am an employer providing the following workers' compensation coverage for my employees working on this job. • An ranee Company Policy Number 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: ---,---,--•-• • • ,1- . . . Name of Contractor . Insurance Company/Policy Number . Name of Contractor - Insurance Company/Policy Number • " - • Name of Contractor Insurance Company/Policy Number 9 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 fora 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 overage verification and that failure to;ccure coverage as required under Section 25A'of MGL 152 can lead to the impoiition of criminal penalties consisting of a fine of up to$1500.00 and/or i •risonment of up to one year and civil penalties in the form of a Stop Work Order and a fine 01 5100.00 a d again Signed this A. .�Sa� �! (" day of V/3 , 19 ?-- / 41/ Licerset Permi;.et \, Licensor/Permiaor r ' Suggested Affidavit for Home Improvement Contractor Permit Application For Office Use Only NANkE O CITY/I.OWN Permit No, uue�,'t c\� Date AI•I.1UAVIT Home Improvement Contractor Law Supplement to Permit Application MOL c.142A requires that the"reconstruction.alteration.renovation.renair,modernization.conversion.inprovement,removal.demolition. or construction of an addition to any pre-existing owner-occuoted building containing at least one hut not more t hon.four dwelling units....or to structures which are adjacent to such residence or building"bedone by registered contractors,with certain exceptions,along with other requirements. Type of Work: ( ke 1kb5f CAl ( � pan Est. Costal 0� Address of Work / � ` YVY"1 (4) tai - �12\Anc\J � , Owner Name: �}J' Xt_ DA erk C tAA/� Date of Permit Application: D (3 192 I hereby certify that: Registration is not required for the following rcason(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: • `t3 a, Ptii\A (?\n‘k‘ t �-S JOYS7 / 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