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Home My WebLink AboutBLD-93-661 -s is ;7o TOWN OF YARMOUTH 0 ...is.�,1 y' • MATTACME 5' 4.r es): ...„0, f'.% Application for a Permit to Build No. 66/ UPON FINAL APPROVAL ay_ 1,21—f3 MAP S9 LOT 6P 3S- FEE MUST ACCOMPANY THIS APPLICATION. DATE A - 30, 19 93 The undersigned hereby applies for a permit to build n3I/13 according to the following specifications 1. Name of property owner 6-F0RC,-5 CH4fl4LLAS Tel. .R?-(--7-f•sB Address .to c,4-- Cn,iia. PI/ Sc, )14,-~,t1--- 2. 4,-~, `h2.Name of Architect(if any) Tel. 3. Name of builder G&DI? P,/I3 &( lam ddress3 Atom DOMf5,rA 4. License No. Tel. 34- 0831 5. Name of Mason _Address 6. License No. Tel.e 7. Construction address 1/45DCAI CAP2--A//0 OaO. Ss`411011097-44 Flood G District do_ '16 8. Date of subdivision Approval plain zone Zone 9. Private dwelling A Estimated Cost DO NOT WRITE IN THIS SPACE Type of room No. 10. Multi family 0 28& . ° f 2r'�p pias 1 11. Commercial 0 Re roa9 $�' Kit Hen $ Xnsl4(I Fell Dining Rm. 12. Other 0 • .in&tiii ✓en�S 3:1cock 13. No. of stories i . Living Am. Bed Rm. 14. Foundation — Full' Half 0 Crawl 0 Slab 0 Bath 15. Materials — Wood 0 Cement 0 Other , P Deck 16. Type of heat — Oil 0 Gas 0 Electric ❑ Other ❑ Closed porch 17. Garage — 1 0 2 0 Family Rm. Sun room 18. Swimming pool - Size Garage 19. Storage shed — Size I 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.A. No. /07333 �I LOT RELEASED BY Signature .cam PLANNING BOARD Address --3 .1/2-n.-,1-, DA Date So . i ,r ,t S , ildei 67466.-, F/3a/'3 ,PEs BUILDING DLPARTMENT ' -----"" .CONSTRUCTION SUPERVISOR FORM LEASE PRINT: ' .. . . .. .. - - _ OB LOCATION: 0 A jai -C r IL._Sr s r 4 tan t NUMBER ren! 'I^ STREET VILLAGE • • WNER OF PROPERTY: ' C e0r_I-R�&�E� MVO p1A1-M3 /��j p ONSTRUCTION SUPERVISOR: �7� h D4V )5 3-I`l - OO �/�f�-� w ( 52, NAME 'MEWL. LICENSE NO. PHONE NO. ' IDRESS: 3 / & O - 'KoAD , n A .. . 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, RE.`!OVAL OR DEMOLIIION INVOLVING THE STRUCTURAL ELEPIENTS OF BUILDING AND STRUCTURES ONLY PURSUANT TO THE STATE BUILDING CODE AND ALL OTHER APPLICABLE LAWS OF THE -0`2•!ONWEALTH, EVEN THOUGH HE, THE LICENSE• HOLDER, IS NOT THE PERMIT HOLDER BUT ONLY A SUB- ONTRACTOR OR CONTRACTOR TO THE PERMIT HOLDER. _.15.3 THE LICENSE HOLDER SHALL I2IEDIATELY NOTIFY THE BUILDING OFFICIAL IN WRITING OF THE ISCOVERY 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 TH?ER 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 .:3E CCNSTRUCTION SUPERVISOR WHO IS TO SUPERVISE THOSE PERSONS ENGAGED IN CONSTRUCTION, RECON- STRUCTION, ALTERATION, REPAIR, REMOVAL OF DE.`!OL'ITION AS REGULATED BY SECTION 109.1.1 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 CN THE RECORDS OF THE BUILDING DEPARTMENT. I HAVE READ AND UNDERSTAND MY RESPONSIBILITIES UNDER TEE RULES AND REGULATIONS .FOR LICENSING CC' STRUCTION SUPERVISORS IN ACCORDANCE ..ITH SECTION 109.1.1 OF THE STATE BUILDING CODE. I UNDERSTX L-F. CONSTRUCTION INSPECTION PROCEDURES AND THE SPECIFIC INSPECTION AS CALLED FOR BY THE BUILDIN FFICIAL. INSURANCE COVERAGE: • • I have a carmen liability insurance policy cr its substantial equivalent which meets the requirements ct MGL+rh.152 Yes No ❑ It ycu have checked vet. please incia.e the type cverage verage by checking the a::,.criate bex. � ! ti A Iiabity incur:rice pc,icy oV Cther type of '.,cemnity 0 Bcnd 0 CVINER•_ INSURANCE' WAIVER: I am aware that the t:c_nsee dc__ re! he:•P the in., a.. . _ cc•:er:^,e rec.::rec - Chapter 152 ct the Ma_:. Genera L-ws. ant tat ,ny ar .,.re cn perm:: : c_,cn waives this ret::irer-..._ • -• Check one: CwnerO Agent 0 S.g.:c;,:ro ct C..nerrcr L'*ceerr s Avant _'�r =sa.� = COMMONWEALTH OF MASSACHUSETTS - . ,, _ n ,�EIAIr:ivfEivTOFINDUSTRIAL ACCIDENTS •- -..__ gif - 600 WASHINGTON STREET James Canape!: BOSTON, MASSACHUSETTS 02111 rormssone WORKERS' COMPENSATION INSURANCE AFFIDAVIT • • I, 6Pra,sf at0S (licensee/permittee) • • with a principal place of business/residence an , ,( 03 X tic 24 a n n.� 11 - od()cc . (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 jo . • r A F inc on Fat • Insurance 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 ..• . t • Name of Contractor • Insurance Company/Policy Number 0 I am a homeowner performing all the work myself. NOTE:.Plcue be aware that while homeowners who employ persons to do maintenance.construction or repair work on a dweiiine of not more than three units in which the homeowner aiso resides or on the grounds appurtenant thereto ars not generally considered to be employers under the Workers' Compensation Act(GL C. 152.sect. 1(5)).appiic:lino by a homeowner fora license or permit may evidence the legal status of an employer under the Workers' Compensation Act. I understand :ha:: copy of this statement will be forwarded to the Department of industrial Accidents' Office of lnsuranc for coverage verification and that failure to secure coverage as revuired under Section 25A'of MCI-152 can lead to in: impoiition of criminal penalties consisting of a fine of up to 51500.00 and/or imprisonment of up to one year and Sit penalties in the errs of a Stop'Work Order and a fine of 5100.00 a day against me. /) S Signed rhis -30 day of Al--/ , 19 g3 L icease_iPerrnl t: Li:tnso^P:rmta:r Suggested Affidavit for Home Improvement Contractor Permit Application • For Omce Use onlyNAME OF CITY/I'OWN Permit No. S,Y�4IC HOIJT-H Date AFFIDAVIT Home Improvement Contractor Law • Supplement to Permit Application MGT-c.142A requires that the"reconstruction.alteration,renovation.remir,modernization,conversion,inprovement,removal.demolition. orconstntction of an addition to any pre-existing owner.ccuoied building containing at least one but not more Than four duelling units....or to structures which are adjacent to such residence or building"be done by registered contractors,with certain exceptions,along with other requirements. /� Type of Work: RL- - kcomN& a- Est. Cost ] Address of Work 501 (Aril)/N CteOcrt"It_-}C1) S'MAth ou7j46 ' " ` Owner Name: O&7 CM HJ4aAS Date of Permit Application: 9 30 _q3 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 MOL c. 142A. Signed under penalties of perjury: I hereby apply for a permit as the agent of the owner: pp 1 .7/9.92 G�� f,,,3 R,-Oers #p7 3R3 Da Contractor a Registration No. OR: • Notwithstanding the above notice, I hereby apply for a permit as the owner of the above property- Date Owner Name