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Home My WebLink AboutBLD-93-619 Y 626{ tit &bp... $�. vr �,�o TOWN OF YARMOUTH 0 f.t"� i H MATTACHI 3• cs,,tM.M..., g. Ap • lication for a Permit to Build No. (01ICI 9. I ,c113 UPON FINAL APPROVAL MAP /(P L Ll./ 7 Z FEE MUST ACCOMPANY THIS APPLICATION. DATE -12_ Q3'The undersigned hereby applies for a permit to build r73 according to the following specificationsWain1. Name of property owner 1-46WaIJ [.n W s4/1,C0 Tel. 776-82€7 Address 1 A 1( Cur. 3'r 11.-cAoo1-kat 401AM 2.Name of Architect(if any) Tel. 3. Name of builder —Fro 1 (41A1 IS Address '7s S1t1h,, )L 4. License No. 13 uu $4/ Tel. .- a 1), 120S- 5. Name of Mason _ Address 6. License No. Tel. `, 7. Construction address 1 4/q�q v ' 1` n Flood C District /� o� 8. Date of subdivision Approval plain zone Zone 9. Private dwelling M Estimated Cost De9NOT WRITE IN THIS SPACE ,� /, Type of room No. !' 10. Multi family 0 3 d y 11. Commercial 0 5-/X// /?(A2.4- / . r-- Kitch , 12. Other / ( i 700 Dining Rm. 13. No. of stories Living Rm. Bed Rm. 14. Foundation — Full ki Half 0 Crawl 0 Slab 0 Bath 15. Materials — Woody Cement 0 Other 0 Deck • 16.Type of heat — Oil 171/Gas 0 Electric 0 Other ❑ 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. l O Cf?it (� LOT RELEASED BY Signatur- � U PLANNING BOARD Addres - .. Date &) tia invu4 A'Ul e2 Lc Ce q_ ) • — COMMONWEALTH OF MASSACHUSETTS _ - . . .DEPARTMENT OF INDUSTRIAL ACCIDENTS _. __- ._ -- - tL\ c 600 WASHINGTON STREET • - _____ rames Campoel; BOSTON, MASSACHUSETTS 02111 • • Conn ss,one: WORKERS' COMPENSATION INSURANCE AFFIDAVIT • • (licensee/permit-Etc) • with a principal place of business/residence ar. - • - - - . —2g S4--Calk4- C PrP Alt Lice v tact)i-k ;4_ (S a 6 6 4 . . (City/Stare/Zip) l . --.,..-. . 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 - . 1)] I am a sole proprietor and hive no one working forme. ' - . " .. - [Kam 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 cad ( r^s U ler C dvn nut-y- er/ 6 ni">nn K iorto3" Name of Contractor . .. Insurance Company/Policy Number . . .. . M! e� / /L M/ /IaM �` ' ` ,&-yy, YYt Cvr i al GL(}Jlil 4/dc Name of Contractor - • Insurance Company/Policy Number - .. . - a • Name of Contractor Insurance Company/Policy Number _ 0 1 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 iecure coverage as required under Section 25A'of MGL 152 can lead to the imposition of criminal penalties • consisting of a line of up to SI 500.00 and/or imprisonment of up to one year and civil penalties in the form of a Stop Work Order and a fine of$100.00 a day against me. Signed th'. 1( 9 day of ./lUgf,c, 4— , 19 0 offilip Licensee/Per . ince' LicensoriPermiaor I `r • r TOWN OF YARMOUTH , i. • BUILDING DEPARTMENT , CONSTRUCTION SUPERVISOR FORM PLEASE PRINT: . JOB LOCATION: ( /A ICrmiNG ih CL crT a v VGrwY'h NUMBER `�r!, / STREET VILLAG OWNER OF PROPERTY: - - 'tom'/.JcArc� •A/ct fiin,..uC2 CONSTRUCTION SUPERVISOR: ` i ',2‘). LL/ • �Q (`s •• • 4�18y� G -/7o r NAME ///, LICENSE okay. PHONE NO. •. , , ADDRESS:' ' -223" >4.4. 'f'/Iin ,424,4_ . • Sd `24 V vw<i - .. - .. .'r 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, REIOVAL 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 DEPARTYINT. 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: t I have a current )ability insurance policy or its substantial equivalent which meets the requirements of MGLth.152' Yes {J( No ❑ r If you have chec ed ves, please indicate the type c:verage by checking the ap^,rcpriate box. i, • 5, A liability insurance pc:icy k O:her type of :.idemnity 0 Bond 0 •• . • • OWNER'S INSURANCE WAIVER: I am aware that the licensee dcei rot have the insurance coverage require:: !-.y.. Chapter the Mass: General Laws, ana that my signature on this permit ccplication waives this requirement Check one: OwnerD Agent 0 • natur i ()owner a Owner s Agit . C SIGNATUR4 : ) BUILDING OFFICIAL APPROVAL: : . . Suggested Affidavit for Home Improvement Contractor Permit Application For Office Use Only NAME OF CITY/TOWN Pc rmlt No. Date AFFIDAVIT Home Improvement Contractor Law • Supplement to Permit Application MGL e 142A requires that the"reconstruction.alteration,renovation.repair.modernization.conversion.inprovement,removal.demolition. or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than,four dwelling units....or to structures which are adiacent to such residence or building"be done by registered contractors,with certain exceptions,along with other requirements. ( Type of Work: S- 1(.e OI- seII 1� // Est. Coste3(c5O Address of Work 1 A `I (1 tVt. [!(yT"(c1V vt&•vC'vt . Owner Name: H( J2,Ua!'tilt al,c4ry D % Date of Permit Application: 6/9 3 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) Notice is hcrcby 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 ply for a permit as the agent of the owner: // z.3 —40 —ray Lis/5 Apr/77 Dat 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