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Home My WebLink AboutBLD-93-662 i _ --. ,-oistiii. ." oKFew k�. "s t4-P.O' TOWN OF YARMOUTH vs 1/93 (SA_ % .` y, MATTA��[[S �1 ` V,,t ,..,� O, Application forga Permit to Build No. f4l0 a UPON FINAL APPROVAL P .31 -93 MAP S-7 LOT 3 J-5-2 FEE MUST ACCOMPANY THIS APPLICATION. DATE / 7 19 -, ? The undersigned hereby applies for a permit to build Sf a f/95 according to the following specifications pj3//%3 1. Name of property owner Nom.A R �/ Tel. Address fcc / ,,w r- 1.3.-,,A( D 2.Name of Architect(if any) Tel. 3. Name of builderT l [r-1-1 h«.t_k Address A 771/ ,i L I, 4. License No. A&r77's Tel. 7 7 c - 77 C 5. Name of Mason Address 6. License No. Tel. n I 7. Construction address -�.=-.=r-c '&5 I4ftltfeR 3t'nnk ad• SS•4- Flood District 8. Date of subdivision Approval plain zone C: Zone fa-Ko 9. Private dwelling 0 Estimated Cost DO NOT WRITE IN THIS SPACE 10. Multi family 0 (So 0 - A35 Tye room No. 11. Commercial 0 ✓ t r.jo re rum I Kitchen S / 12.Other 0 [sj/�b + �� Dining Rm. Y'c, f !, c vrti4- 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 lit line Side line 25. H.I.C.R. No. /oRc(i LOT RELEASED BY Signat = /..l t. PLANNING BOARD Address '-) ) Cl, fp('t i / h Date {-1 y/. ,. �rf r_ BUILDING DEPARTMENT -.-- __ =-CONSTRUCTION SUPERVISOR FORM - _ _______ _ 1 LEASE PRINT: OB LOCATION: c j Lp c e v. IR r. r, < V ' hvti a L{{ NUMBER , . STREET VILLAGE • • WNER OF PROPERTY: . �r ^ t c >'Vp—Jti_pa ru ONSTRUCTION SUPERVISOR: 7-77_11J t—Cr 1-i cc� (— u 'L • 'I0 7 G/t 7 5 7 77C 3 NAME LICENSE NO. PHONE NO. • )DRESS: - 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 IS 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 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 LA' S OF THE OMMONWEALTH, EVEN THOUGH HE, THE LICENSE HOLDER, IS NOT THE PERMIT HOLDER BUT ONLY A SUB— "ONTRACTOR OR CONTRACTOR TO THE PERMIT HOLDER. -- 2. 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. 2.15. 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 THE CONSTRUCTION SUPERVISOR WHO IS TO SUPERVISE THOSE PERSONS ENGAGED IN CONSTRUCTION, RECON— STRUCTION, ALTERATION, REPAIR, REMOVAL OF DEMOLITION AS REGULATED BY SECTION 109.1.1 OF THE r "ODE 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 N THE.RECORDS OF THE BUILDING DEPARTMENT. I HAVE READ AND UNDERSTAND MY RESPONSIBILITIES UNDER TEE RULES AND REGULATIONS .FOR LICENSING CC: . TRUC:ION SUPERVISORS IN ACCORDANCE WITH SECTION 109.1.1 OF TEE STATE BUILDING CODE. I U1DERST : L::E CONSTRUCTION INSPECTION PROCEDURES AND THE SPECIFIC INSPECTION AS CALLED FOR BY THE BUILDIN FFICIAL. • INSURANCE COVERAGE: • . I have a current +ability insurance pclicy cr s substantiJ equivalent which meets the requirements cf MGL'C1.152 Yes lG . No ❑ If you have checked_ piazze incic to the tyde cave:age by checking _ the a:C.criate b A liability insuranceypc:cyl Cher type of '.,cemnity 0 Send 0 CWNE V: INSURANCE WAIVER: I am aware that the :.censee dces "ct !'"Ie the it ccver g recu:rec Ch 152 ct th ' ..2::. Gene= L'ws, are ,nat my ._re en permit _cm:ic don waives this requirercn-• Checx cite: (*net Agent 0 5 _::;ro ct C•*net ct U.ner s:..;:tit cN .. • • • ` ` ' =� COMMONWEALTH OF MASSACHUSETTS . --DE PARI:'NT OF INDUSTRIAL ACCIDENTS 600 WASHINGTON STREET James J Camopei, BOSTON, MASSACHUSETTS 02111 Gomes•sstoner WORKERS' COMPENSATION INSURANCE AFFIDAVIT • I. `1-7e L kit (licensee/permiaee) • with a principal rt //pllace of business/residence a 77 6a (phi ` 1n /'l-r9PtPr /15 /fil nJ Cel (City/Start/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. • ()S L Gti ka • Insurance Company Policy Number • [ J I am a sole proprietor and have no one working for me. [ J 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 dweiiirg 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 Accidents' Office of insurance for coverage verification and that failure to secure coverage as required under Section 25A'of MGL 152 can Icad to the imposition o:criminal penalties consisting of a fine 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 me. Signed this 3 r day of , , 19 7 7 .__ pe.:-t nso ;Perini-or 1 • Suggested Affidavit for Home Improvement Contractor Permit Application • For Office use Only NAME OF CITY/TOWN Permit No. Date AFFIDAVIT Rome Improvement Contractor Law • . Supplement to Permit Application • MGLc.142A requires that the"reconstruction.alteration.renovation.repair,modernization,conversion.i nprovement,removal.demolition. orconstruction of an addition to any pre-ccistinq owner-occupied building containinQat least one but not more than four dwelling units....or to structures which are adtacent to such residence or building"be done by registered contractors,with certain exceptions,along with other requirements. Type of Work: p Est. Cost (SOv Address of Work •S w,r , k p ' . Owner Name: , Afn-Vit h, Date of Permit Application: I hereby certify that: Registration is not required for the following reason(s): • • Work excluded by law lob 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 -11 c. I42A. Signed under penalties of perjury: I hereby apply for a permit as the agent of theowner: / f Date (^F rtt- ...e0c�r /O 8 teSs 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