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Home My WebLink AboutBLD-93-647 kAti vrr ` :Oc ' TOWN OF YARMOUTH tea. MATTA.C1 411 :Con:: 5 g% ..Application for a Permit to Build No. 6 V7 UPON FINAL APPROVAL % MAP n LOT ' X 9 FEE MUST ACCOMPANY THIS APPLICATION. • DATE -ZV ra�/9� The undersigned hereby applies for a permit to build /ac ording to the following specifications MA-1-4"0 A-1-4"J + ROBM ) �fgiJ6At ill1 Tel.31Cr"/r& Address 2- SPPucc Sr- 3 . yAeovou71-1 , eINJame l f ame of Architect(if any) Tel. /3. Name of builder PI N . 14AK6C2- (Alta Address 120 62-Fig►f WS57 ZAJ Po -, 4. License No. CLI SI 3 S Tel. )6 0 - tCZv 5. Name of Mason N f ft Address 6. License No. Tel. q4Wiled-'‘Lbjti 7. Construction address E District 8. Date of subdivision Approval plain zone Do Zone g"..2.-S- 9. "..2-S 9. Private dwelling 0 Estimated Cost / DO NOT WRITE IN THIS SPACE 10. Multi family 0 0.00- Type of room No. 11. Commercial 0 Kitchen 12. Other 0 Dining Rm. u Living Rm. 13. No. of stories Bed Rm. ` 14. Foundation — Full 0 Half 0 Crawl 0 Slab 0 ,0-0 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 0 2 ❑ Family Rm. Sun room 18. Swimming pool - Size Garage 19. Storage shed — Size eke - Shed F( r / 2a 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 - e No. of feet side 8 No. of feet rear 8 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. 1 6937ti �,f�I LOT RELEASED BY Signature Wi • PLANNING BOARD. Address IZD 6REI WES/E ni £0. Date ` Cum I9 , MA- 0 TOWN OF YARMOUTH BUILDING DEPARTMENT • CONSTRUCTION SUPERVISOR FORM PLEASE PRINT: JOB LOCATION: .e S pe - 57 ' S. `(� anourff • NUMBER • . . /� STREET VILLAGE •. OWNER OF PROPERTY: ' ' �MetA-) '4- N HAN Mis,goBat t-1 • . . • . • •• CONSTRUCTION SUPERVISOR: • •ilg-€IES O !f 1 eteg✓ ' • U� 76� 7 3v NpME .. LICENSE NO.. PHONE NO. . . • ADDRESS:' JI}O . U7 / a/kSei� - Fa • J, -OF�Nc'SJ ' 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 COWIONWEALTH, 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. 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 I}21EDIATELY CEASE UNTIL A SUCCESSOR LICENSE HOLDER IS SUBSTITUTED ON THE RECORDS OF THE BUILDING DEPART`ENT. I HAVE READ AND UNDERSTAND MY RESPONSIBILITIES UNDER THE RULES AND REGULATIONS \FOR LICENSING CC:T- STRUCTION SUPERVISORS IN ACCORDANCE WITH SECTION 109.1.1 OF THE STATE BUILDING CODE. I UNDERSTA:N: THE CONSTRUCTION INSPECTION PROCEDURES AND THE SPECIFIC INSPECTION AS CALLED FOR BY THE BUILDING OFFICIAL. ' . . INSURANCE ERACE: I have a curre bility insurance policy or its substantial equivalent which meets the requirements of MCLth.152 . Yes . No O If you have the ked v`s, please indicate the type cwerage by checking the ap;rcpriate bcx. : A liability insurance pclicy) Other type of :idemnity 0 Bond 0 ' OWNER'_, �•0.ANCE WAIVER: I am aware that the ncensee does rot have the insurance coverage requires `:y Chapter Li7T7 he Mass: G neral Laws, no tha y signature on this permit :;plication waives this requirerrert Check one: -'�� Ownero Agent 0 Sign= a o lner or Ooner s Agent • SIGNATURE: BUILDING OFFICIAL APPROVAL: ~ PLOT PLAN . FOR LOT # Indicate location of garage or accessory building Additions with dashed lines Sewerage disposal (cesspool) . Well 0 - I (lot ft. rear) • — — — — 0 Abuttor's 1 _. �' Abutt Name - Name Lot # .,• I • r Lot # REAR YARD ` ' If this is a .$` •4 If thi corner lot, l ft. corn- write in name • writ of street. I name ..; _ � ry a other •:0, 0• ` aci street P • ra I • • • • SIDE YARD IDE YARD • HOUSE h FT. 0 • . . . �] — - - - FTO • • • Q • • I . SET BACK • ft • •• I 0 • (lot ft. frontage) .. • 2- SPRuce Sr / N / (NAME OF STREET) / <\ -Information / 6-17-1:v•-•• / ytit-^,41.�•t'rn / \ Supplied by ✓✓ 0 • COMMONWEALTH OF MASSACHUSETTS = E DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 WASHINGTON STREET tames J Camvoei; BOSTON, MASSACHUSETTS 02111 • rpmm,ssroner WORKERS' COMPENSATION INSURANCE AFFIDAVIT • 1, Rh. F 13c (licensee/permittee) • with a principal place of business/residence at 12—o (Meer u` S a S 01 (City/State/Zip) do hereby certify, under the pains and penalties of perjury,that: 1 am an employer providing the following workers' compensation coverage for my employees working on this Io . 0E-WA- 023369&5'ECfA • Insurance Company Policy Number [ ) I am a sole proprietor and have no one working for me. • [ ) 1 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 - 1 am a homeowner performing all the work myself. NOTE.Pleue 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(CL C. 152,sect. 1(5)),application by a homeowner fora license or permit may evidence the legal status of an employer under the Workers' Compensation Act. I understand that:copy of this statement will be forwarded to the Department of Industrial Accidents' Office of lnsurande for coverage verification and that failure to secure coverage u required under Section 25A'of MGL 152 can lead to the imposition of criminal penalties • consisting of a fine of up to $1500.00 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. r Signed this day of abpicr , 19 3 • Licer see/tact LiccnsoriPermirtor