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Home My WebLink AboutBLD-93-653 ;,$ o . TOWN OF YARMOUTH / l 4!Acka. 61 t MATTACCCS J 6013Vtt .,te•�g Application for a Permit to Build No. UPON FINAL APPROVAL 0 k" 13 MAP 0-1._Cr LOT N Y FEE MUST ACCOMPANY THIS APPLICATION. DATE a-'7 19 0%.- The f The undersigned hereby applies for a permit to build 1/V- /q3 according to the following specifications 44 ame of property owner �",` - Tel. 7 7 5 3YO Address ��"",�� .e.-.4-+,P 12 2.Name ofArchitect(ifany) �'t Iad'0 -?S 0 'A Tel. CJ3. Name of builder tic/miff/2 Address 4. License No. Tel. 5. Name of Mason Address 6. License No. Tel c -7tonstruction address 37 'yl O i-ct--114.. # /2 11/24-tffick...r- Flood �_ District Q �(-'— 8. Date of subdivision Approval plain zone Zone 9. Private dwelling 0 Estimated Cost l DO'NOT WRITE I Tproom THIS SPACE _ No. 10. Multi family 0 y 11. Commercial ❑ / a Kitchen 12. Other _ 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 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. /1 LOT RELEASED BY S gnature e' 6 PLANNING BOAR ----AAddress i�R 6 3� _ Date *Ceti_ — TOWN OF YAMOUTII • - -w • BUILDING DEPARTMENT HOMEOWNER LICENSE EXEMPTION PLEASE PRINT: DATE /a 719�3 5013 LOCATION 37 rePC'o4-- e. 24,--J ff Qa fl �4 • NUMBER STREET ADDRESS SECTION OF;TOWN oriEOWNER" e- ' - 77-V 3 3 A, ' NAME HOME PHONE WORK PHONE (,.RESENT ILING ADRESS '¢�}& , C 1 Qjyuai- �V ¢r".� ��TTTT "VA a a 47,3 CITY OR TOWN STATE ZIP CODE THE CURRENT EXEMPTION FOR "HOMEOWNER" WAS EXTENDED TO INCLUDE OWNER—OCCUPIED . • DWELLINGS OF SIX UNITS OR LESS AND TO ALLOW SUCH HOMEOWNERS TO ENGAGE AN IN— DIVIDUAL FOR HIRE WHO DOES NOT POSSESS A LICENSE, PROVIDED THAT DIE OWNER ACTS AS SUPERVISOR. (STATE BUILDING CODE SECTION 109.1.1) • DEFINITION OF HOMEOWNER: PERSON(S) WHO OWNS A PARCEL OF LAND ON WHICHIIE/SITE RESIDES OR INTENDS TO RE— SIDE, ON WHICH THERE IS, OR IS INTENDED TO BE A ONE TO SIX FAMILY DWELLING, ATTACHED OR DETACHED STRUCTURES ACCESSORY TO SUCH USE AND/OR FARM STRUCTURES. A PERSON WHO CONSTRUCTS MORE THAN ONE HOME IN A TWO—YEAR PERIOD SHALL NOT BE CONSIDERED A HOMEOWNER. SUCH "HOMEOWNER" SHALL SUBMIT TO T11E BUILDING OFFICIAL, ON A FORM ACCEPTABLE TO THE BUILDING OFFICIAL, THAT HE/SHE SHALL BE RESPONSIBLE FOR ALL SUCH WORK PERFORMED UNDER THE BUILDING PERMIT. (SECTION 109.1.1) THE UNDERSIGNED "HOMEOWNER" ASSUMES RESPONSIBILITY FOR COMPLIANCE WITH TUE STATE BUILDING CODE AND OTHER APPLICABLE CODES, BY—LAWS, RULES AND REGULATIONS. THE UNDERSIGNED "HOMEOWNER" CE•RTIIIES THAT HE/SHE UNDERSTANDS THE TOWN OF YARMOUTH BUILDING DEPARTMENT MINIMUM INSPECTION PROCEDURES AND REQUIREMENTS AND THAT HE/SHE -' WILL COMPLY WITH SAID PROCEDURES AND REQUI• r 1 NTS. YHOMEOWNER'S SIGNATURE C/11 6_'A4r-- • APPROVAL OF BUILDING OFFICIO? NOTE: THREE FAMILY DWELLINGS 35,000 CITRIC FEET, OR LARGER, WILL BE REQUIR= TO COMPLY WITH STATE BUILDING CODE SECTION 127.0, CONSTRUCTION CONTROL. INSURANCE COVERAGE: I have a current 'ability insurance poiicy or its substantial equivalent which meets the requirements of MGL Ch. 142. YesNo ❑ If you have checked ves, please indicate the type coverage by checking the apprcpriate box. A liability Insurance pcficy 0 Cther type cf indemnity 0 Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does nct have the insurance e coverage re qu ire d by y Chapter 142 of the Mass. Ge errl Laws, and that myz!gna1e cn this permit appl:catlcn waives this requirement. Check one: e-e--- . 5 cIgna:;::e cr cr cr On..=r a • COMMONWEALTH OF MASSACHUSETTS _ - - _ . _ ' ° 'DEPARTMENT OF INDUSTRIAL ACCIDENTS , . - • • 600 WASHINGTON STREET James J CamDpeu BOSTON, MASSACHUSETTS 02111 dorm:ss:oner WORKERS' COMPENSATION INSURANCE AFFIDAVIT • • • lar e1, 404 Wit- °life n o (licensee/permit-tee) • • with a principal place of business/residence at: (City/Stam/Zip) do hereby certify, under the pains and penalties of perjury, that: - [ J 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 worldn: for me. • I am a sole proprietor, general contractor .r homeown (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 XI 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 dwciiing of not more than three unit in wait: 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 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 saternent will lx forwarded to the Department of Industrial Accidents'Office of Insurance for coverage verification and that failure to iceure coverage as required under Section 25A'of MGL 152 can lead to tie impoiidon of criminal penalties consisting of a fmc 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 mc. / Signed thi f a/pi air dam-- day of �� 19 'ic.r.tee Perrain V Licc ..onTzrmr::::r • • . . Ls 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 • ' MGL C I42A requires that the"reconstruction.alteration.renovation.reaain modernization.conversion.inprovement,removal,demolition. • or construction elan addition to anv ore-existing 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 aceptions,along with other requirements. The of Work: C.Fiz,"/ t / / ( Est Cost &>B.tea-. - _. Address of Work 3, Wee d,,4.. 4-30 4/P..-C �0wner Name: rel2-' to Cyd -✓' U// e--'Date of Permit Application: .)-V7 J I hereby certify that: - Registration is not required for the following reason(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: Date Contractor Name Registration No. OR: • Notwithstanding the above notice, I hereby apply for a .'rmit as the owner of the above property: v L 'f/ Date encr Name ,