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Home My WebLink AboutBLD-93-635 ek 4 a-V5_ : 4 41o'. TOWN OF YARMOUTH .4 H coMpuTTAC"` ' ' Application fora Permit to Build No. �,,4°..�.,�•��,%' APP (o `�`� . .. UPON FINAL APPROVAL . . gA P3 ys LOT 4 3 FEE MUST ACCOMPANY THIS APPLICATION. 7 DATE 5/2l9 19 The undersigned hereby applies for a permit to build Vat 9_3 according to the following specifications�/ "' '`' 4' ' ` V21#931. Name of property owner &iKett iticzi.1 toil! • Tel.311P-2-717 ??� Address - all Lka... S f` 2.Name of Architect(if any) Tel. a Name of builder 1V c4 a ffcc.r/i�'�-1 Address 30 S4 cleat- MA S- V4` 4. License No. 60 6 2l( Tel. 3 I g Y cis,' 5. Name of Mason Address 6. License No. Tel. 7. Construction address 541146- z'7 t-PA°/11,0y•--)-- ' s Flood District 8. Date of subdivision Approval '' plain zone Zone 9. Private dwelling 0 Estimated Cost �Q0 NOT WRITE IN THIS SPACE 10. Multi family 0 166-00 Type room I 11. Commercial 0 5/74Pg At ita .( d Kitchen�/ 12. Other /trid 4 Spy 4 ep_co -- Dining Rm. 13. No. of stories Living Rm. 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 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 LOT RELEASED BY Signature 444 PLANNING BOARD Address rr Sisr e•- rYU. �p Date 5. (4ali.4.p1.c 10 14 / 1 • BUILDING DEPARTMENT 1 -S . CONSTRUCTION SUPERVISOR FORM PLEASE PRINT: JOB LOCATION: tre44. 2o6 1 tat /fr.. 5 /.' 5 Ir NUMBER .�• . STREET . . VILLAGE OWNER OF PROPERTY: ' Ke.rjel /Veteic,[j - • `J • CONSTRUCTION SUPERVISOR: It ic.4.4 DereM�4tt.• DCiEkt i S7 9'�/bfir? . :; ;`. ; ., f L'+ ' -. NAME LICENSE'NO:'.e PHONE NO. • ADDRESS: 3L3 it U. S.Yet&tetlet,' • LICENSED DESIGNEE: F ' . . ,. .. ' • ) ‘....' . ..1,1 (IF OTHER.THAN SUPERVISOR) "NAME • 'a `:" -i " ' . .•r LICENSE NO. 2.15 RESPONSIBILITY OF EACH LICENSE HOLDER: . ••• '!. . ,' . 0 • .' r.. , _:', , . ' 4 • • ' 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 CO`U1ONWEALTH, 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 WHICIrA$E COVERED B'f .THE BUILDING PERMIT. 2.15.4 ANY'LICENSEE`VtIO'SHALL WILLFULLY '•VIOLATE SUBSECTIONS 2.415.1,12.15.2 OR 2.15.3 OR ANY OTHER SECTION OF THESE RULES AND REGULATIONS AND ANY PROCEDURES, • AS'AMENDED, SHALL BE 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 DD: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 I}2IEDIATELY 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 CC STRUCTION SUPERVISORS IN ACCORDANCE WITH SECTION 109.1.1 OF THE STATE BUILDING CODE. I UNDERSTA: THE CONSTRUCTION INSPECTION PROCEDURES AND THE SPECIFIC INSPECTION AS CALLED FOR BY THE BUILDIN OFFICIAL. INSURANCE COVERAGE: . I have a curre tenability insurance policy or its substantial equivalent which meets the requirements of MGLth.152 ' Yes J . No ❑ If you have pecked v_<<_, please indicate the type coverage by checking the accrcpriate box. l A liability insurance pciicy 0 Cher type ct :.:demndy ❑ eond ❑ 1 . OWNER'S INSURANCE WAIVER: I am aware that the c ensee deeS rbt hove the insurar.ce coverrge require: Chapter152 of the Mass• General L_-•Ns, anc that my signature on tn:s permit.Tp.iccttcq waives this req_ire.•r.era ' • , I CheC1F bne: - 5 O.vner e ).y Ager.: 0 Signa;ora of O..ner or Omer s:.gent ,4t SIGNATURE:) - ,e�G�L __BUILDING OFFICIAL APPROVAL: • ,a • �' ==' COMMONWEALTH OF MASSACHUSETTS �^ sG - DEPART.MEN'T OF INDUSTRIAL ACCIDENTS . . . _ . - . - 600 WASHINGTON STREET t • James.: Campoel. BOSTON;MASSACHUSETTS 02111 14�..c4r `9 comm:ss one' WORKERS' COMPENSATION INSURANCE AFFIDAVIT %• I, AraQcl eiliec:;/ ' ' I (licensee/permittee)P ., a / "..„ • with a principal lace ofbusines's/residcnce'a1 "'" r ' .y 30 s Icat;•• vf-i. s_ yam KA-0 . (City/Stitt/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 ' I am a sole proprietor and have no one working for me. a]" I am a sole proprietor, gene .s . r or homeowner (circle one) and have hired the contractors listed below who have the following workers' c. pensation insurance policies: g"telms.1 ` oma•o strfe Asp 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,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 undersand 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 iccure covers a as reouired under Schon 25A'of MCL 152 earn lead to the imposition of criminal penalties constsan.t of: fine of up to 51500.00 and/or imprisonment of up to one year and civil penalties in the form of:Stop Work Order and a fine of 5100.00 a day against me. Sicncd :his �'� ? ., day of J u , 19 �3 Licc_ Lc ��I✓ r'/ c.asc: P:.mer._. i` t41 y