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Home My WebLink AboutBLD-93-652 $-$. r h o TOWN OF YARMOUTH lTTACM[ $ �I MA .Jig Application for a Permit to Build No. 650-i UPON FINAL APPROVAL �/ gea7443 MAP 77 LOT Lu- i 2-- FEE FEE MUST ACCOMPANY THIS APPLICATION. DATE e`ZS 19 qi The undersigned hereby applies for a permit to build �ga��3 according to the following specifications � d/� 1. Name of property owner Eliz-e-� srv. O 2��3q3 ce, 393$ Address $135 netraorfre A'e 5'°- 1RVwk 2.Name of Architect(if any) C { Tel. 3. Name of builder f^lk . 3Wt'C- -tv. Address 234 Fa C- yik-v' 4. License No. Oil 31.0 Tel. 3QM $444 V 5. Name of Mason Address 6. License No. Tel. 7. Construction address S tsW`t- tC3 P- "C sp yifi. is �<-�- Floo• f� D"istr"ict 8. Date of subdivision Approval plain zone L Zone 9. Private dwelling Er Estimated Cost DO NOT WRITE IN THIS SPACE 5:772/9, gc,tev f= Type of room No. 10. Multi family 0 42.o01,0.tt) PC-Pin Mt.Pitt.' !/ nL4rt 11. Commercial 0 -Kitchen 12. Other 0 Dining Rm. 13. No. of stories 1 Living Rm. S1 0� 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 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. l 02.10910 ar ,9 LOT RELEASED BY Signature "- PLANNING BOARD Addr=. s 2-4- Z,vrolk-4"- kc Date _ C. (I • BUILDING DEPARTMENT • __ ___.CONSTRUCTION SUPERVISOR FORM .. _ _ _ . LEASE PRINT: ' ' OB LOCATION: 5' \ �tAW� c rwe y_Wc1ut• MVI - NUMBE n u ` STREET VILLAGE WNER OF PROPERTY: ' r F '�• s^V.4fJk�j(4 ONSTRUCTION SUPERVISOR: •Cfjknv� V'. \AL\wA ' • 0113lO 31'{ 84442- NA,TfE . •LICENSE NO. PHONE NO. )DRESS: Z� • t�va5-rck., A . Co . yep/ - . ICENSED DESIGNEE: . (IF OTHER THAN SUPERVISOR) NAMELICENSE NO. .15 RESPONSIBILITY OF EACH LICENSE HOLDER: • .15.1 THE LICENSE HOLDER SHALL. BE FULLY AND COMPLETELY RESPONSIBLE FOR ALL WORK FOR WHICH HE S SUPERVISING. HE SHALL BE RESPONSIBLE FOR SEEING THAT ALL WORK IS DONE PURSUANT TO THE STATE UILDING• CODE AND THE DRAWINGS AS APPROVED BY THE BUILDING OFFICIAL .15.2 THE LICENSE HOLDER SHALL BE RESPONSIBLE TO SUPERVISE THE CONSTRUCTION, RECONSTRUCTION, ALTERATION, REPAIR, RD!OVAL OR DEMOLITION INVOLVING THE STRUCTURAL ELEMENTS OF BUILDING VD STRUCTURES ONLY PURSUANT TO THE STATE BUILDING CODE AND ALL OTHER APPLICABLE LAWS OF THE -0:24ONWEALTH, EVEN THOUGH HE, THE LICENSE HOLDER, IS NOT THE PERMIT HOLDER BUT ONLY A SUB- ONTRACTOR OR CONTRACTOR TO THE PERMIT HOLDER. 4.15.3 THE LICENSE HOLDER SHALL IMEDIATELY NOTIFY THE BUILDING OFFICIAL IN WRITING OF THE ISCOVERY OF ANY VIOLATIONS WHICH ARE COVERED BY THE BUILDING PERMIT. .15.4 ANY LICENSEE WHO SHALL WILLFULLY VIOLATE SUBSECTIONS 2.15.1, 2.15.2 OR 2.15.3 OR ANY THER SECTION OF THESE RULES AND REGULATIONS AND ANY PROCEDURES, AS AMENDED, SHALL 3E SUBJECT 0 REVOCATION OR SUSPENSION OF LICENSE BY THE BOARD. 2.16. ALL BUILDING PERMIT APPLICATIONS SHALL CONTAIN THE NAME, SIGNATURE AND LICENSE NUMBER OF .HE CONSTRUCTION SUPERVISOR WHO IS TO SUPERVISE THOSE PERSONS ENGAGED IN CONSTRUCTION, RECON- °T..UCTION, ALTERATION, REPAIR, REMOVAL OF DE!OLITION AS REGULATED BY SECTION 109.1.. OF THE "ODE AND THESE RULES AND REGULATIONS. IN THE EVENT Tr AT SUCH LICENSEEE IS NO LONGER SUPERVISING AID PERSONS, THE WORK SHALL D.1.-MEDIATELY CEASE UNTIL A SUCCESSOR LICENSE HOLDER IS SUBSTITUTED N THE RECORDS OF THE BUILDING DEPARTMENT. I HAVE READ AND UNDERSTAND MY RESPONSIBILITIES UNDER THE RULES AND REGULATIONS .FOR LICENSING CC' TRUC-ION SUPERVISORS IN ACCORDANCE WITH SECTION 109.1.1 OF THE STATE BUILDING CODE. I UNDERST : _:E CONSTRUCTION INSPECTION PROCEDURES AND THE SPECIFIC INSPECTION AS CALLED FOR BY THE BUILDIN FFICIAL. INSURANCE COVERAGE: • I have a current liability insurance policy cr its substantial equivalent which meets the requirements of MGith.152 Yes ', No ❑ If you have checked plea__ inciczte the type c::era;e by checking the a:_.c_riate box. l A liability insurance pc:icy ❑ Cher type cf ....emn.ty 0 Bond 0 CWNET.. CISURANCE WAIVER: I am aware that the ..censee aces rat hay/. . ., the incur:n _ . ver^ rec_:rec Chapter 152 cf the Ma__. Genera Laws a .. ane , at ,my . _ :Lure en th• pe..-., _:-.,c_..cn waves .his rec_ . Check che: C.vner`; ASen: 0 S;nazura cr e.•.ner Frr0 neer s avant i—c -V.,:‘,..:„ On ia►3 It'= COMMONWEALTH OF MASSACHUSETTS 1.2 DEPA_ c R MF OF INDUSTRIAL ACCIDENTS - - - - 600 WASHINGTON STREET • ,lames J Camvpee BOSTON, MASSACHUSETTS 02111 • Comm:sstpner WORKERS' COMPENSATION INSURANCE AFFIDAVIT • ✓V ) (licensee/permittee) • • with a principal place of business/residence an 24 ms . Come_ co . Ytv (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. ��, CR 'fit-' `5 Co • Insuranc 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: .; .. , • • • • -- 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 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 Acddents' Office of Insurance.for coverage verinca:ion and that failure to iccure coverace as required under Section 25A'of.MGL 152 can lead to tie imposition of criminal penalties consisting of a fine of up to 51500.00 and/or imprisonment of up to one year and diff penalties in the form of a Stop Work Order and a fine of 5100.00 a .��ag . . al ea this (�_ ! 2 ST day of Att..3- , 1901?) Li._..so:iP:rmtaor w♦ • • 0 In accordance with the provisions of MGL c 40, S 54, a condition of Building Permit • Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 111, S • 150A. The debris will be disposed of in: • gMwto,;Askt �o.A..r.N. +w.kp (Location of Facility) • @:).4- Signature of Permit Applicant - ekas- • Dte �'- Suggested Affidavit for Home Improvement Contractor Permit Application For Office Use Only NAME OF CITY/TOWN Permit No. Date AFFIDAVIT Home Improvement Contractor Law • Supplement to Permit Application MGLc.142A requires that the"reconstruction,alteration.renovation.renair,moderniration,conversion.inprovement,removal,demolition. orconstruction of an addition to any preexisting owneroccumed building containing!!least one but not more than four dwelling umts....or to structures which are adjacent to such residence nr building"be done by registered contractors,with certain exceptions,along with other requirements. Com., '�y llllY- 11 Type of Work: S"f• l C611\rvgl� re-or Est. Cost 2000 Address of Work 8-4; c,..J0 4_ Owner Name: ' Ek%tC\ocirt,, tJ.gav‘ Date of Permit Application: $CZS 0.3 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 a ply for a permit as the agent of the owner: 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