HomeMy WebLinkAboutBLD-93-639 a4afic tJ t/zs
- ro TOWNOF YARMOUTH or3
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V'�t..• 6% Application.for a'Permit"to Build No.
UPON FINAL APPROVAL g/�3✓9MAP Nis-P-/ L CU7
FEE MUST ACCOMPANY THIS APPLICATION. DATE l a 3 19 93
The undersigned hereby applies for a permit to build a3/93
according to the following sp catiops
1. Name of property owner ?c��2SJ ievNe r�-t0A-L Tel.
Address - ?) /Los's ,� S' c ielif M
2.Name ofArchitect(if any) 1r' \. " • I. / Tel,
3. Name of builder 'cEf A-NSr o e ;` -ZZ.- ' Addressir ca( 7 71fdn.nirn� ti
r.
4. License No. 0000,10 �" 7e1;°`? ?) -.V/ 6-
,R,,"-es
.fir ., ,
5. Name of Mason r0-: .`.r`-'Yc ".� . �r ; " ` ,- Address
6. License No. # Tel e a' ' 6/
7. Construction address 3 o go f C / n S. c74n-^"
Flood District ��_
8. Date of subdivision Approval plain zone C' Zone
9. Private dwelling Estimated Cost NOT WRITE IN
T THISpeof SPACEroom No.
10. Multi family 0 /0 a o o j
11. Commercial ❑/2•Ef�(,f,(/f� r / ' ' yc� Kitchen
12. Other L. 0 /'' / Dining Rm.
13. No. of stories Z 5-570r-- Living Rm.
Bed Rm.
14. Foundation — Full* Half 0 Crawl 0 Slab 0 Bath
15. Materials — Wood 0 Cement 0 Other 0 • Deck _
16.Type of heat — Oil 1 1 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.LC.R. No. /Do it ,e .
e '`"4
PLANNING BOARD ' - ,i Address F f1/ a :-./.1;-•c_
Date 02/7 i ' -"- '-' )^-
/1---/y147,/,---er
`� (? BUILDING PERMIT APPLICATION SIGN OFF
APPLICANT: /=/NNE/-fdJ a, // BUILDING PERMIT It:
ADDRESS: 30 6 y- cam/ TELE. NO. : DATE FILED:
BLDG. SITE LOCATION: MAP//: ,�Z LOT//: 10 7
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 COMMERCIAL 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:
6. 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
_= =x COMMONWEALTH OF MASSACHUSETTS . •
• _��' • . DEPARTMENT OF INDUSTRIAL ACCIDENTS - -
' 600 WASHINGTON STREET
names CamDoel; BOSTON, MASSACHUSEI IS 02111
romm ssroner WORKERS' COMPENSATION INSURANCE AFFIDAVIT •
•
•
(licensee/permi nee) -
• with a principal place of business/residence an
(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.
&fl' l rA( AJ Ns • •
Insurance Company Policy Number
[ ) I 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: — .1- .
Name of ContractorInsurance 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,sect. 1(5)), application by a homeowner for a license
or permit may evidence the legal sums 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 overage
verification and that failure to secure overage as required under Section 25A'of MGL 152 can lead to the imposition of criminal penalties
consisting 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 5100.00 a day against me.
Signed is ?✓ day of �' t� , 19
Ce-C, 6 000 ?
IcerseelPermiree' Licer..soriPcrmiror
• ,, S
Suggested Affidavit for Home Improvement Contractor Permit Application
For Office Use Only • NAME OF CITY/I.OWN
Permit No.
Date
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
MGL a 142A requires that the"reconstruct ion.alteration.renovation,repair,modernization.conversion.inprovement,removal.demolition,
or construction of an addition to any preexisting owner-occupied building containing at 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: �rl �IA—rr� 2 4 ff—]ZO ✓ at. Cost ZD/t°0
Address of Work ,? go ic / J C./A&.
Owner Name: 2p/o ,tQ4 n/ti C s+.-i v
Date of Permit Application: 6723 / 73
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:
8 A3 /72 Oc /Y- - ,0 /00 /02
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