The URL can be used to link to this page

Home My WebLink AboutBLD-93-658 0VZ'A `•, k ' II .$- S€ ` 0' TOWN OF YARMOUTH Y o MAwCM[ s ` 6V Q es,,4 to- , Application for a Permit to Build No. g. g3D - 93 UPON FINAL APPROVAL ,/ MAP Ir. 3 LOT a' elo FEE MUST ACCOMPANY,THISAPPLICAT►ON. DATE 7/5O 19 9 D The undersigned hereby applies for a permit to build 1(30/ 93 according to the following specifications Cid n • "1. Name of property owner"' V�i`A J ,rG{ A Tel.'')/' $lO V ' Address `WO ) AA.) iSt W Y4 n ..� 2.Name ofArchitect(if�ny) f Tel. a Name of builder „__L�fl✓�..� Address 1 ' � � .�.. L / 2vLt 4 cL 4. License No. 0cct G b TeL 1)9 o — riga, 5. Name of Mason Address 6. License No. Tel. 7. Construction address y v A nLAO .s A+. Li kCstq r'...,,d,, i Flood District 4-8. Date of subdivision Approval plain zone C- , Zone �'�� 9. Private dwelling 0 Estimated Cost DO NOT WRITE IN THIS SPACE Ci 10. Multi family 0 (49 ex CJS t'- te�F - Type of room No. peg W _ erPnr2. 11. Commercial ❑�1{� [1 Kitchen 12. Other gpuur, S(frp 4 utf Dining Rm. 13. No. of stories Living Rm. �`n 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. /0 .R90_ LOT RELEASED BY , Signature _ n1^^,--•- PLANNING BOARD Addres '7 Co.4+,..-// 7r Pelt_ Date 'Ci 7Gn r.o t t__ i I.mss. COMMONWEALTH OF_MASSACHUSETTS -. *-^' • . DEMI- MENT OF INDUSTRIAL ACCIDENTS , • >-4l 600 WASHINGTON STREET James CanineBOSTON, MASSACHUSETTS 02111 - comm:ssonet WORKERS' COMPENSATION INSURANCE AFFIDAVIT (licensee/permittee) • • with a principal place of business/residence an 34( C eie .-t- �� 4./ r-rrew e ill 02093 (City/Sure/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 [ 1 am a sole proprietor and have no one wonting 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 - s Name of Contractor • Insurance Company/Policy Number 0 I am a homeowner performing all the work myself. NOTEt.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 ars 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 statement will be forwarded to the Department of Industrial Accidents' Office of Insurance for coverage verification and that failure to icccre coverate as repuired under Section 25A'of MGL 152 can lead to the imposition of criminal penalties consiso:ng of a fine of up to 51500.00 and/or imprisonment of up to one year and div penalties in the form of a Stop Work Order and a fine of 5100.00 a day again::me. ,� Q Signed this(9J\ 62I day of �/J V , 19 -/ 3 • L.,_rr:JPerrnir._. Lic....sor;P:rmittor — TOWN OF YARMOUTH I t" - - --: : • BUILDING DEPARTMENT • CONSTRUCTION SUPERVISOR FORM •• PLEASE PRINT: n' • 15)1,4_,. r_. .I JOB LOCATION: yo ' 4 *,5 •• "i/ fC^��^ . . • • • NUMBER (7 l ' . STREET VILLAGE OWNER OF PROPERTY: '' �e-i"19' .Jt,j, ,di- (� CONSTRUCTION SUPERVISOR: . • JO•�n 1 V—pape,r-.. • Qc. 7c x / gffi'�ZCI;Z . NAME/ -AVL • j ' { (LICENSE NO. . PHONE NO. . • _ . ADDRESS: D y ��ir�e / : `l�� 7` ` `� yam_ 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, RE•SOVAL 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 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} EDIATELY 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 CON- STRUCTION SUPERVISORS IN ACCORDANCE WITH SECTION 109.1.1 OF THE STATE BUILDING CODE. I UNDERSTAN: THE CONSTRUCTION INSPECTION PROCEDURES AND THE SPECIFIC INSPECTION AS CALLED FOR BY THE BUILDING OFFICIAL. • • INSURANCE COVERAGE: . I have a current liab"ty insurance policy or its substantial equivalent which meets the requirements of MGLth.152 • Yes r. . No ❑ • It you have checked.= please indicate the type c average by checking the apprcpriate box. . A liability insurance pc:icy -CY Other type of :.idemnity 0 Bond 0 • OWNER'S INSURANCE WAIVER: I am aware that the ucensee does not have the Insurance coverage required tv Chapter 152 of the Mass: General Laws, and that my signature on this permit :cplica:icn waives this requirerrer.. • Check one: , • • Owner❑ Agent 0 ' Signature of 0,4ner or Owners Agent • ' SIGNATURE: O' 0 BUILDING OFFICIAL APPROVAL: �' • •-• 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.142A requires that the"reconst ruction.alteration.renewal ion.repair,modernization.conversion,inprovement,removal,demolition. orconstruction of an addition to any pre- cistine owner-occupied buildins_containing at least one hut not more than four dwelling units....or to structures which are adjacent to such residence or huildins"be done by registered contractors,with certain exceptions,along with other requirements. Type of Work: Per o n ;1 Est. Cost 9 9 Address of Work `v0 Owner Name: V at-pt c C k r, t Date of Permit Application: • I hereby certify that: Registration is not required for the following reason(s): _Work excluded by law - _ t55 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 7/70A, /cro2 2 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 0 % %.• • • • o . In accordAnce with the provisions of MGL c 40, S 54, a condition of Building Permit - Number (o,.,3, Docfr,r 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: • (Location of Facility) • • OOCAt ' `�� ` Signature of Permit Applicant . `57:i1/DeZ Date • .. •