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itat
o TOWN OF YARMOUTH
0 A —H,
'•� MATTACN[ l
eC4 �e rES g Application for a Permit to Build No. boW
UPON FINAL APPROVAL O - 1 �l - • — MAP 1/ LOT I} 101
FEE MUST ACCOMPANY THIS APPLICATION. DATE t//9 19 7 3 •
The undersigned hereby applies for a permit to build PP 9/95
according to the following specifications /�j�
1. Name of property owner '//A �o„•..4 Cee- _ wl�sr pgmedrif Tel.
Address as Wadi,, acu
2.Name ofArchtit c (if any) Tel.
3. Name of bui SYN 4' ddress 229/ C S-eawac.4-4
4. License No. 0 Y n fay Tel.
5. Name of Mason Address
6. License No. Tel. /� 1
7. Construction address �'{e? Qo.4. 4 e�-4- 4,_04 • W
Flood District n- Y Q,
8. Date of subdivision Approval plain zone Zone
9. Private dwelling 0 Estimated Cost DO NOT WRITE IN THIS SPACE
jZ/p - "a, s°F f Type11°X-171
pof room No.
10. Multi family 0 / r X11 I aPet - lrwricr9' r► a-pmt / _
11. Commercial ❑ - • Kitchen
12. Other 0 Dining Rm.
e Cit 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 ❑ 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. •/0 .2 3 c7,.Z
LOT RELEASED BY Signature 5-Cr°-.0 O'Vele°"
PLANNING BOARD Address c2F/ �^ •-Q c
Date
, * CONSTRUCTION SUPERVISOR FORM . • .
k l
PLEASE PRINT:
JOB LOCATION: ` ' . XIN y �'ne C
t7( LA/ kH/gm.
• : • NUMBER ' . - /� %J /�STREET . . VILLAGE'
OWNER OF PROPERTY: ' • f X44;4,4 • `/:-�M4]�
CONSTRUCTION SUPERVISOR: _ 1. j 6 r , 0 /✓jot-fsv [�, t . •0h'0 i& )7•y sae E
NAME LICENSE NO. PHONE NO. . .
ADDRESS: a `II c-i
• LICENSED DESIGNEE: •
(IF OTHER THAN SUPERVISOR) NLME LICENSE NO. .
2.15 RESPONSIBILITY OF EACH LICENSE HOLDER:
2.15.1 THE LICENSE HOLDER SHALL BE FULLY AND COin3LETELY RESPONSIBLE FOR ALL WORK FOR WHICH HE
IS SUPERVISING. HE SHALL BE RESPONSIBLE FOR SEEING THAT ALL WORK IS DONE PURSUANT TO-THE-STAT
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, RD OVAL OR DEMOLITION INVOLVING THE STRUCTURAL ELEMENTS OF BUILDING
AND STRUCTURES ONLY PURSUANT TO THE STATE BUILDING CODE AND ALL OTHER APPLICABLE LAWS OF THE
CC}C1ON.cALTH, EVEN THOUGH HE, THE LICENSE HOLDER, IS NOT THE PERMIT HOLDER BUT ONLY A SUB •
—
CONTRICTOR 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 VIOL;TIONS 1,1iICH 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 SUPERVISIN
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 C
STRUCTION SUPERVISORS IN ACCORDANCE WITH SECTION 109.1.1 OF THE STATE BUILDING CODE. I UNDERST
THE CONSTRUCTION INSFECTION PROCEDURES AND THE SPECIFIC INSPECTION AS CALLED FOR BY THE BUILDI
OFFICIAL.
•
INSURANCE COVERACEE: . .
. t • . . ... .. .
I have a C..,ent ability inscr_ree ;clicy cr is :ub:i n :al e:.valent which meet: the re:� 'toih
rements ct .152
Ye: .. No 17 . . .- . .. . ..
It ycu have checked v_s plea incitz.e the type c:vers;: by checking the ap_..pr ate bcx. .
A Iiat:ity in:ur:nce :::!::y 0 ether type of :.ieamn ty 0 Lacnd Q �•
CWHER'3 INSURANCE WAIVER: I am aware that the rcen:ee dcei 'cw
t " • the in:urar.: cc -_;
vere rr 'rec :y
C a r 152 6att tth��e Ma•:. General L•ws, aro ,nat my :t;r::ure cn permit _:c:::c..cn waive: this ; :itemer
Crr,er.. Agent C
S.zea:_:a e: ...net
c:t;.r.er: gent
SIGNATURE: fix;, U ! 10.14.21.,‘ BUILDING OFFICIAL APPROVAL:
n =•=
I
• ;• Suggested Affidavit for Home Improvement Contractor Permit Application ....
For Office Use Only NAME OF CITY/TOWN
Permit No.
Date
• Al-r11)AVIT
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-misting owner-occupied buildingcnntainingat least one but 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. �]
Type of Work: Roof aet//e , ,.vt o Est. Cost / Co 0
Address of Work 22 ' & eigdi• Q np 'p94M
Owner Name: raAn1I - 4/J,-LR�+�-
Date of Permit Application: 5//y 3 .
I hereby certify that:
Registration is not required for the following reason(s): •
_Work excluded by law
_Job under $1,000
_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:
i1/9�93 a2/7e-t..4,` /0 a 34 a
Date Contractor am Registration No.
OR: •
Notwithstanding the above notice, I hereby apply for a permit as the owner of the above property:
Date Owner Name