HomeMy WebLinkAboutBLD-93-615 `^ o 'YAk 69)644
c��, r , o TOWN OF YARMOUTH Dora) eke/9i
0t Y 'mi ` / `,
e6,7,,-,0 = ; Application for a Permit to Build No.
� '`f
UPON FINAL APPROVAL �' 0$46-93 MAP 37 L P 3
FEE MUST ACCOMPANY THIS APPLICATION. DATE i(p 19 C(
The undersigned hereby applies fora permit to build g 1 g f q
or
accing to the following specifications I 1
Name of property owner Ronald 11►ortOvi Tel. SW-69/7
Address 99 L;brr-f-y br.1 $ 11reLn<GIry/YIA nicf.5.
2.Name of Architect(if any) Tel.
l/3:Name of builder Ote-Wine. Address
4. License No. Tel.
5. Name of Mason _Address
6. License No. Tel.
-,--TConstruction address 7 7 TO uJ/J 13ROOK ROAD
Flood District
8. Date of subdivision Approval plain zone C- Zone R r y0
9. Private dwelling 0 1 stimated Cost r DO NOT WRITE IN THIS SPACE
y,�,„,� � aiType of room No.
10. Multi family 0 laSO �'y" ypepofi o
S I
11. Commercial 0 / Kitchen
12.Other Y •(,� 04•i-.s "'/ Dining Rm.
----ft.�
13. No. of stories Ion ... "4-4--4
4� # Living Rm.
Bed Rm.
14. Foundation — Full 0 Ha f ❑ Crawl 0 Slab ❑ 337:dui 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 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. H.I.C.R. No.
LOT RELEASED BY 2.--"Signature itirvid,
ai)`
PLANNING BOARD 4........./Address 414 Ligrr-fY Dr.
Date Shrewcbur y MA
KICANT: RQvta id. ii/or2=e) iiBUILDING PERMIT V: 1
4�4�,1�51 ss: V? Li6 er-f7 �65ArrV B19'01-69/ 7ELE. NO. : � -69/ 7 DATE FILED: t.
t1SL'[)G. SITE LOCATION: 77 T tjij BROOK ROpbbMAP;I: � LOTl1:
THE FOLLOWING INFORMATION OUTLINES THE PROCEDURAL STEPS REQUIRED TO OBTAIN A PERMIT TO BUILD,
ALTER, OR ADD TO A STRUCTURE WITHIN THE TOWN OF YARMOUTH. THE BUILDING DEPARTMENT WILL DETER-
MINE COMPLIANCE TO THE FOLLOWING (A) ZONING REQUIREMENTS (B) HISTORICAL DISTRICTS (C) FLOOD'•
PLAINS ZONING. THE BUILDING DEPARTMENT WILL BE RESPONSIBLE FOR ASSISTING THE APPLICANT THOUGH
THE FOLLOWING DEPARTMENTS:
RESIDENTIAL AND/OR COiTi1ERCIAL BUILDING
•
WATER DEPARTMENT: DETERMINES COMPLIANCE OF WATER AVAILABILITY.
ENGINEERING DEPARTMENT: DETERMINES COMPLIANCE FOR PARKING AND DRAINAGE.
CONSERVATION COMMISSION: DETERMINES COMPLIANCE TO WETLANDS ACTS, I.E. : IF LOT(S) BORDER ANY
TYPE OF WETLANDS, STREAMS, PONDS, RIVERS, OCEANS, BOGS, BAYS, MARSH
LAND, ETC.
HEALTH. DEPARTMENT: DETERMINES COMPLIANCE TO STATE AND TOWN REGULATIONS, I.E. : REQUIRE'
MENTS FOR SEPTAGE DISPOSAL AND OTHER PUBLIC HEALTH ACTIVITIES.
FIRE DEPARTMENT: DETERMINES COMPLIANCE TO STATE AND TOWN REQUIREMENTS FOR PERSONAL
SAFETY, PROPERTY PROTECTION, I.E. , SMOKE DETECTORS, SPRINKLER SYSTEMS
ETC.
THE FOLLOWING DEPARTMENTS MUST SIGN OFF, IN THE RESPECTIVE ORDER, PRIOR TO BUILDING INSPECTOR
ISSUING THE REQUIRED BUILDING PERMIT:
REVIEWED BY:
1. WATER DEPARTMENT DATE: N/A:
2. ENGINEERING DEPARTMENT: DATE: N/A:
3. CONSERVATION: DATE: N/A:
4. HEALTH DEPARTMENT DATE: N/A:
INDUSTRIAL AND/OR COMMERCIAL PERMITS •
•
5. WIRING INSPECTOR: DATE: N/A:
G. PLUMBING INSPECTOR: DATE: N/A:
7. FIRE DEPARTMENT: DATE: N/A:
PLEASE NOTE
ALL STUMPS AND/OR BRUSH MUST BE DISPOSED OF AT AN APPROVED SITE. A SIGNED RECEIPT FROM THE
DISPOSAL SITE MUST BE SUBMITTED TO THE BUILDING DEPARTMENT PRIOR TO ISSUANCE OF THE BUILDING
PERMIT.
COMMENTS:
BLM/89 •
//r L
PLOT PLAN •
• .
i
FOR LOT # i
e
a
Indicate location of garage or accessory building kw
Additions with dashed lines
Sewerage disposal (cesspool)
. Well E
•
I (lot ft. rear)
Abuttor1 s I Abutt
Name IName
Lot # ' I • Lot j #
REAR YARD i
If this is a •
If thi
corner lot, 1 ft. corne.
write in name write
of street. lc name
;-2. � • •a ..oth'er
' -p• cu treet
ra8
��a`'`te /la_ ••
SIDE YARD . SIDE YARD
• HOUSE
0 FT. 0 0 FT.0,
-Cr
. .
' •
SET BACK
•
-: • . . • ft.
I .
(lot ft. frontage) ..
/ 1/ 7 7 Yown Brno k Road
N /
N / (NAME OF STREET)
•
•
/ / \� Information L� �i� ' _
/ Supplied by e
\ /
TOWN OF YAMOUTH
BUILDING DEPARTMENT
•
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
DATE .$
1-153 LOCATION 77 / OWN BROOK ROAD
NUMBER • L STREET ADDRESS SECTION OF,TOWN -
OMEOWNER" X Dna let Kort it 74'c2"(D4/ 7
NAME - . - - HOME PHONE WORK PHONE •
•
(,PRESENT MAILING ADRESS 2f Q Ll nf-?, Dr.
ShrT'UJSbur Jf14 Ois'fS
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/SHE 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/SHE SHALL BE RESPONSIBLE
FOR ALL SUCH WORK PERFORMED UNDER TILE BUILDING PERMIT. (SECTION 109.1.1)
11IE UNDERSIGNED "HOMEOWNER" ASSUMES RESPONSIBILITY FOR COMPLIANCE WITH THE STATE
BUILDING CODE AND OTHER APPLICABLE CODES, BY—LAWS, RULES AND REGULATIONS. •
THE UNDERSIGNED "HOMEOWNER"•CE•RTIPIES TUAT HE/SHE UNDERSTANDS THE TOWN OF YARMOUTH
BUILDING DEPARTMENT MINIMUM INSPECTION PROCEDURES AND REQUIREMENTS AND THAT HE/SHE '
WILL COMPLY WITH SAID PROCEDURES AND REQUI' aI TS.
OWNER'S SIGNATURE 708/4_04✓
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:
1 have a current liability insurance pc!icy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes ❑ No ❑
If you have checked vest 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 142 of the Mass. General Laws, and that my signature cn this permit application waives this requirement.
• • Check one:
at"
• OwnerAgent
Signature ct Coster or Owner s Agent — _
} = COMMONWEALTH OF MASSACHUSETTS
-
�' �_�_r-•• DEIAIrMTFitT OF INDUSTRIAL ACCIDENTS '111
600 WASHINGTON STREET 1
James Campoe�: BOSTON, MASSACHUSETTS 02111 • y
S .
Comn:ssione• •
WORKERS' COMPENSATION INSURANCE AFFIDAVIT
1-, l \ 0Kaid /10✓'76vl
(licensee/permirtcc) )
• with a principal place of business/residence an •
47-"*".------ a a
(City/Site/Zip) t
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 thi
I
job. r
•
Insurance Company Policy Number 1
1 am a sole proprietor and have no one working for mc.
AQ , am a sole proprietor, rener.,l contractor o.i.omcowner (circle one) and have hired the conerectors listed below
who have the following workers' compensation insurance policies:
Name of Contractor • Insurance Company/Policy Number
Name of Contactor Insurance Company/Policy Number •
Name of Cont.—actor Insurance Company/Policy Number
am a homeowner performing all the work myself.
•
NOTE:.Plcuc be await that while homeowners who emnioy persons to do maintenance, ecestruaioc or repair work on :
dweiiin: of not more than three units in which the homeowner iso resides or on the ;rounds appur_emit thereto are not centrally
considered to be employers under the Worken' Compensation At: (CL C 152.sect. 1(5)). application by a homeowner for a license
or permit may evidence the Iec-.1 status of an employer under the Workers' Compensation Act
•
1 undtmtanc t..., : cony of this statement will be forwarded to the ricpa.^.ment of industrial Accidents' CfF.e: 0,11ns:tr.:rid for coverace
venue:::oat and Cr.:: failure to se_ure cove.--r a recuired under S_^on 25..'oi`ICL 152 lead to t.: ims^o;iti:n of criminal penalties ccn;i;cat of: line of un to �;cin_ 500.00 a- o:srnprssonmer : rare or uto one year evil pe..aic:s bthe e f_.m of:_ -: 'Sork Order and a
fine et 5100.00 a day ac:ins:ma.
•
.: this /Gdr: or /4u5 US f 143
• •..ai� �•i. c
1N
_ Y
Suggested Affidavit for Home Improvement Contractor Permit Application
For Omce Use Only NAME OF CITY/TOWN
Permit No. d
Data '
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 any pre-aiming owner-occunted budding containing at least one hut not more than four dwelling units....or •
to structures which are adjacent to such residence or building"be done by registered contractors,with certain exceptions,along with other
requirements. (�,,�j: fuZt OM hCuSA) L�
Type of Work: / et.._r,ddIle?ate/.ot.-n 04".07C Est. CosMa SCS
ress of Work 77 frbajA, BR to.'c ROA 15
-vner Name: /`X(9 via Ed KD r ze) vt
Date of Permit Application: $— l 6 -?3
I hereby certify that:
Reeistration is not required for the following reason(s):
_Work excluded by law
Job under S1,000
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, I hereby apply for a permit as the owner of the above property:
!� —t6-73 '—
Date Owner Name