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HomeMy WebLinkAboutBLD-93-630 E .� yr :�o TOWN OF YARMOUTH oKEE`' • MATTACHEES Pr? ecZka dww* ; Application fora Permit to Build No. 63� UPON FINAL APPROVAL MAP AO LOT K ? FEE MUST ACCOMPANY THIS APPLICATION. DATE PA 3 "19- 93 ` The undersigned hereby applies for a permit to build ViZ i9a according to the following specifications 1. Name of property owner in/ILL/4m AAS)/r..n y Tel. 29Y^Wilt Address //2 !21:11,1K4din,' qr../K t/ T 2.Name of Architect(if any) Tel. 3. Name of builder /27/z /l/c,Gcatsan/ Address 42 771/s !may 4. License No. On S"8-. Tel. Sap 4/Zr-Ver-zr 5. Name of Mason Address 6. License No. 0/6/3S 8' Tel. t 2_fr 4/fl P-- 7. "7. Construction address //7 PAw/<,4n'.✓4,,,b4oT ,pD /e1,y 8. Date of subdivision Approval plain zone Vise (art ill Z me ct R_ 2-S 9. Private dwelling Pam Estimated CostDO11OT WRITE IN THIS SPACE 10. Multi family 0 -P X36 oo ,. '5 -It a.Rera, Type of room No. 11. Commercial 0 ra ebb, Kitchen 12. Other 0 - Dining Rm. 13. No. of stories i Living Rm. Bed Am. 14. Foundation — Full 0 Half 0 Crawl 0 Slab 0 e2--., c a 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 ❑ " 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. /00S60 - - LOT RELEASED BY Signature /17/{1 /(/ r.^-4------- PLANNING - PLANNING BOARD Address /3 xipthi Date . . TOWN OF YARMOUTH • BUILDING DEPARTMENT `' - �' CONSTRUCTION SUPERVISOR FORM PLEASE PRINT: ' 'nn frrnauff/ JOB LOCATION: //e2 Era w KR tia/aw tfvv_%NUMBER . STREET GE OWNER OF PROPERTY: ' it/ILL/4m • ,AaCA(taA ( U CONSTRUCTION SUPERVISOR: me/✓/CiercgJ'ON / ©tatc7 /�' Cer-L-7,9-' NAME LICENSE'NO. PHONE NO. ADDRESS: 42 77-Ps wilY Q5i cevfcer• - LICENSED DESIGNEE: • ' (IF OTHER.THAN SUPERVISOR) NAMELICENSE 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, RE1OVAL OR DEMOLITION INVOLVING THE STRUCTURAL ELEMENTS OF BUILDING AND STRUCTURES ONLY PURSUANT TO THE STATE BUILDING CODE AND ALL OTHER APPLICABLE LAWS OF THE COMONWEALTH, 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. • t 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 DEPARTENT. I HAVE READ AND UNDERSTAND MY RESPONSIBILITIES UNDER THE RULES AND REGULATIONS ,FOR LICENSING CC:I- STRUCTION SUPERVISORS IN ACCORDANCE WITH SECTION 109.1.1 OF THE STATE BUILDING CODE. I UNDERST;2: 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 MGLth.152 Yes Y ; . No ❑ If you have checked vis, please ✓incicate the type cwerage by checking the ap:rcpriate box. A liability insurance pc:icy !�asOther type of :.idemnity 0 Bond 0 ' OWNER'S INSURANCE WAIVER: I am aware that the licensee does rot have the insurance coverage requirec v• Chapter 192 of the Mass. General Laws, ano that my signature on this permit :cp:icaticn waives this requiremer..t Check one: OwnerO Agent 0 Signature of Omer cr Own- s ad-nt �/ SIGNATURE: I/ , 1 ad BUILDING OFFICIAL APPROVAL: ~ suggested Affidavit for Home Improvement Contractor Permit Application For Office Use Only • NAME OF CITY/TOWN Permit No. Date AI r1DAVIT 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-existing owner-occupied building containing at least one but not more than fourdwelling units....or to structures which are adjacent to such residence or budding"be done by registered contractors,with certain exceptions,along with other requirements. Type of Work: tQen,ov< 44-errAirCE —loop Est. Cost &COO .— Address of Work /19 at,K /,tnrA/,/CW Ku?' • Owner Name: l+//tt iro A,ASHergif Date of Permit Application: Hot. .27 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 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: PVC 079—Q3 4K n4CKer/CCOA/ /oo S& 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 • k' = ' ` COMMONWEALTH OF MASSACHUSETTS .__.: _ . _2,e . . DEPARTMENT OF LNDUSTRIALACCIDENTS 1 600 WASHINGTON STREET : James J CampbellBOSTON, MASSACHUSETTS 02111 - • cpmmrss,oner • WORKERS' COMPENSATION INSURANCE AFFIDAVIT • I, n fl//Cf�t2S'Dpt/ . (licensee/permittee) • with a principal place of business/residence an DSir' Over r /274 ail FCC (City/State/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. Insurance Company Policy Number 1 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: •-•• --• - . . .. . • Name of Contractor . . -. Insurance Company/Policy Number:. . .... ,. . . Name of Contractor - - • Insurance Company/Policy Number - . . - . . .. - Name of Contractor Insurance Company/Policy Number . _ 0 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,net. 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 secure coverage as required under Section 25A'of MGL 152 can lead to the impoiition of criminal penalties • consisdog of a fine of up to 51500.00 and/or imprisonment of up to one year and civil penalties in the form of a Stop Work Order and a fine of S100.00 a day against me. Signed this sa�ii / day of ,40&. , 19 93 l/?a ,i/_. - _ Licensee/Permit-tee LicensoriPermi;,or