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Home My WebLink AboutBLD-93-636 ncydcis , o TOWN OF YARMOUTH H tit... ""' $ Application for a Permit to Build No. �a.3( �,,��..,ar��- UPON FINAL APPROVAL 0 ?' 413 MAP '2_3 L. 3 FEE MUST ACCOMPANY THIS APPLICATION. DATE The undersigned hereby applies for a permit to build ' Z4/73 according to the following specifications V24/72 72 1. Name of property owner 7 C-e/7/7a 01 eRL 0 Tel. e?g*/ �3G 71- Address 2a c( 5 '.s• .� a? 2.Name ofArchitect(ifany) A v11' Tel. 3. Name of builder_Fe/ply/& Imre(( Address //o 1 'ij tA/e, ot-v Jae 4. License No. Tel. 77C 76 S/ 5. Name of Mason Address 6. License No. Tel. 7. Construction address as N 50 S,f02F t7JZ. FloodDistrict 8. Date of subdivision Approval plain zone , Zone a.3 U 9. Private dwelling '-s Estimated Cost DO NOT WRITE IN THIS SPACE S S� Type of room No. 10. Multi family 0 l 411. Commercial 0 5Rrein � R e1a1,gci n y ( 957 nleS rt hen 12. Other 0 7.;•y 1e prgpe.,f '-z k1 Dining Rm. avow/. Living Rm. 13. No. of stories (2,) auoCLi*VG LOvl'e/� �"• ,... , Bed Rm. 14. Foundation — Full Ci"Half 0 Crawl 0 Slab 0 Bath 15. Materials — Wood 0 Cement 0 Other 0 Deck 1e 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 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. ' /OI 3-0 ? LOT RELEASED BY Signature !!h�-..-...-p /14., 7 �/-1v/ 9.--- PLANNING BOARD Address 1.429 2& '-4(-i 5-2/7(24..„. a 4 Date • m,," ,1� ��fi#.23/9a lf ' ` `- • _ COMMONWEALTH OF MASSACHUSETTS: P' =_ •mob �• DEPARTMENT OF INDUSTRIAL ACCIDENTS , ' - - 600 WASHINGTON STREET . James J Canine': BOSTON, MASSACHUSLI 1S 02111 • • C;omm,ss ones WORKERS' COMPENSATION INSURANCE AFFIDAVIT • • I, .4/u( DZ-v/s (I i cen sec/permittee) • with a principal place of business/residence an . //t 4v rn,3G-P/9.v ,.r1, be,-.Y,9cZi. ,. '- (City/Sate/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. . _ _ _._ - O 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 • - . - i • Name of Contractor Insurance Company/Policy Number - Q I am a homeowner performing all the work myself. NOTE.Plcasc 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 homeowoer 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 Inauranci for coverage verification and that failure to iecure coverage as required under Section 25A'of MGL 152 can lead to the impoiitioa of criminal penalties • consisdhg 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 q� 3 day of , 19 .9--; Lic seeiPermi^cc' Licensor/PCtmi:tor . • BUILDING DEPARTMENT - . CONSTRUCTION SUPERVISOR FORM PLEASE PRINT: ' . . . •' • JOB LOCATION: , O 1 40 c c e !, .02 4o yit# Z NUMBER • . STREET VILLAGE OWNER OF PROPERTY: ' O/r4//" P> P7/,'41220-67 CONSTRUCTION SUPERVISOR: , .....0 ,1_. tt' 47i i,7s ' 72f7? 5-/ NAME • LICENSE NO. PHONE NO. ADDRESS: 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, 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 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 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 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 DEPARTMENT. I HAVE READ AND UNDERSTAND MY RESPONSIBILITIES UNDER THE RULES AND REGULATIONS ,FOR LICENSING CCI 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: / have a current •, I have a cliability insurance try or its substantial equivalent which meets the requirements of !.iGLth,152 Yes 9 . No If you have checked v`s. please inc!cte the ype c:verage by checking the ap_:acriate bcx. . A liability insurance pc!icy 0 Other type of :.idemnity 0 8cnd 0 • • OWNER'S I SURANCE WAIVER: I am aware that the ccensee dces rct have the insurance coverage require: =y • Chapter 2 of the Mass. Ge rai Lw ane that my signature cn tr,:s permit aap:icaticn waives this requirememc heck ane: • :ignawre er Aner cr OMn "r s A,ent S GNATURE: . BUILDING OFFICI L PPROV • e • ,. - - - Suggested Affidavit for Home Improvement Contractor Permit Application For Office Use Only NAME OF CITY/TOWN permit No. Dote AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application MGL o.1-12A requires that the"reconstruction.alteration.renovation.repair,modernization.conversion.inprovement.removal.demolition. or construction elan addition to any pre-existing owneroccumed building containing at least one but not more than four dwelling units....or to structures which are adjacent to such residence or pudding"be done by registered contractors,with certain aceptions,along with other • requirements. Type of Work: pe e Est. Cost Address of Work '--o y 5't9 5 f ioR e DoZ S O yflj Owner Name: V/kj/j e fO / &yt Go Date of Permit Application: I hereby certify that: Registration is not required for the following rcason(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: • � y7,7daczaH ,,,c2 ate 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