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Home My WebLink AboutBLD-93-618 .._ . . oFY� ., 0KFev % f o TOWN OF YARMOUTH T/I1'13 o 44 ' H HCs,,:k--..,a�'_' Application for a Permit to Build No._)— UPON FINAL APPROVAL I��3 �' MAP s9 LOT 12 3 it FEE MUST ACCOMPANY THIS APPLICATION. DATE A0 0S-1- 17 19 93 The undersigned hereby applies for a permit to build ti' 7/q3 according to the following specifications 1. Name of property owner Donated TnEyck Tel. 'fhf- 3n9 Address 19a4 Rifin ni-o DR. j }p0,1--ks IJ. V. 8943f 2.Name of Architect(if any) Tel. 3. Name of builder &core a Det v,'s gJaders Address 1 Ycnofr, Roe,d S. ben n .5 4. License No. 05-61 3 0 Tel. 394 - 083a 5. Name of Mason Address 6. License No. Tel. 7. Construction address it4 Co p+a %n Crocker Road, S. Ya r, o .A-h. Flood District k'et/� 8. Date of subdivision Approval plain zone 9. Private dwelling ® Estimated Cost DO NOT WRITE IN THIS SPACE Type of room No. 10. Multi family ❑ 2 Svc? sQ (Z RI s 11. Commercial 0 Pc-sl }z c- ,- kc��cr 16KitchBn 12. Other 0 vrior Y6 C07 tel«-c_. Dining Rm. 13. No. of stories 1 Living Rm. Bed Am. 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 ❑ Closed porch 17. Garage — 1 0 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. 1 in- '333 LOT RELEASED BY Signature PLANNING BOARD Address S'Yuwn t'2 Date . Ate,-e-^5/(iIN- Suggested Affidavit for Home Improvement Contractor Permit Application } For mire Use Only NAME OF CITY/TOWN Permit No. Date -- AFHLAVIT Home Improvement Contractor Law Supplement to Permit Application MGLcN2Arequires that the"reconstruction-alteration.renovation.repair.modernization.conversion.inprovement.removal.demolition. •r or construction of an addition to any prets:stirq owners ccumed huddinz containing at least one hut not more than four dwelling units....or to structures which are adiacent to such residence or huddinz"be done by registered contractors.with certain captions,along with other 't requirements. Type of Work: fooc Re Placer•. a n+ Est. Cost 2 ,S"b Address of Work 44 Cop*'ctJn Crocker Port d. so 4.)+1, i/orer'ao-F),. r Owner Name: Don a f a —re n Ely ck Date of Permit Application: Zi - 1 '1 - 9 • "s i hereby certify that: 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) S. Notice is hereby given that: 1 OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT\VORK DO NOT HAVE • ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL e. I42A. Signed under penalties of perjury: • I hereby apply for a permit as the agent of the owner: 0/7/73 44-/o 733 3 Date Cod tractor Name Registration No. • OR: Notwithstanding the above notice, I hereby apply for a permit as the owner of the above property: Date ONArcr Name ' COMMONWEALTH OF MASSACHUSETTS • • acs-r DEPARTMENTOFINDUSTRIAL ACCIDENTS 600 WASHINGTON STREET James.; Campoel: BOSTON, MASSACHUSETTS 02111 • • rornn.ss:oner • WORKERS' COMPENSATION INSURANCE AFFIDAVIT • • I, George Dct vr'5 (licensee/permit—tee) • with a principal place of business/residence ac • • • 3 Ycrtn/en ennrP, Snst+G. hennaS, Oa ,A0 (Cry/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. D t • • . Insurance Company Policy Number [ ) I am a sole proprieror and have no one working for me. I am a sole proprietor. generel contractor or homeowner (circle one) and have hired the nen:a ors listed below who have the following workers' compensation insuranc policies: Name of Contractor Insurance Company/Policy Number Name of Contractor Insurance Company/Policy Number • Name of Contractor Insurance Company/Policy Numb:: Q 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 dwciiin_ of not more than three units in which the hor_eowner also resides or on the grounds appurtenant thereto are not centrally considered to be employers under the Workers' Compensation Act(CL. C. 151.sect. 1(5)).application by a homeowner for a license or permit may evidence the lett) sums of an employer under the Workers' Compensation Act. I andent:ad that : copy of this statement will be forwarded to the Deportment of industrial Acddents' Cf ce of Insure-1M for coverage verification ane that failure to secure cove.—ace a tecuired under Scc=on 25.'t'oIMal 52 can lead to ;... .mposic:n a criminal penitict cens's tang of: fine of up to 51500.00 anc'or imprisonment of up to one year and dVv penaties is the ferm of: ::Cork Order and 2 lane of 5100.00 a day aclrst mt. dzv c 11 7 (-) l9 ¶ 3 • • • BUILDING DEPARTMENT CONSTRUCTION SUPERVISOR FORM PLEASE PRINT: JOB LOCATION: tJ4 Cap#a ;,, Crocker Road 'Spin-I As—Inb -R r, . NUMBER . STREET VILLAGE OWNER OF PROPERTY: 'Pi A. 'DanaIG! -ten Elick , • CONSTRUCTION SUPERVISOR: George Da...L's Ru i Id e rS bS6 136 • 394- 0113 NA LICENSE NO. PHONE NO. ADDRESS: 3 )4 an,. rennr�. 56 u-1-4. ' Den n )3. MA- OaGc,O . •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 DE*:OLITION 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 LICENSING CCI STRUCTION SUPERVISORS IN ACCORDANCE .KITH SECTION 109.1.1 OF THE STATE BUILDING CODE. I UNDERSTA 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 MGL Ch.152 Yes rim . . No ❑ If you have checked v`s• please ine!ate the type c average by checking the no:rcpriate box. . A liability insurance pc!iosace Other type of :.idemmty 0 Bond 0 • OWNER'S INSURANCE WAIVER: I am aware that the licensee dcei rot have the insurance coverage requires =y • Chapter 152 of the Mass. General Laws• anc that my sig^ature on trs permit :cc:ica:ion waives this requirement , Check one: Owner: Agent 0 SIgnarure of Omer cr()owner s Agent