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HomeMy WebLinkAboutBLD-93-673 :yq Ugf 30/93 ' 7 "r� ' o TOWN OF YARMOUTH © 'crew Irk t1/43 Ei le „o'0 J Application or a Permit to Build No. _cn_ 0 - UPON FINAL APPROVAL q•z-93 MAP 3-2"? LOT 7-- 2?/ FEE MUST ACCOMPAHY;,-;i:iAPPLICATION. DATE19 The undersigned herebtapplies for a permit to build / / according to the following specifications /a, 3 1. Name of property owner I 've. a: �" A a U " 101 .1 Tel. 3°980043 Address io N„. /1/9iPl . ,C7, AI? *J`T 1 M,9ss, M tid 2.Name of Architect(i an%) a A Tel. 3. Name of builder ' 'P11/T), Rc94-- Address.26 go, PAW -57: , 4. License No. ©/2 &6( Tel. S9F &c 3F? 5. Name of Mason l�i Address N /4 6. License No. /i14 • Tel. NM I 7. Construction address �9/ c5 . s,coge d rdz ,5. 7l� Flood R • District 8. Date of subdivision Approval plain zone// I o Zone i”,•D 9. Private dwelling 0 Estimated Cost DO NOT WRITE IN THIS SPACE Type of room No. di 10. Multi family 0 ®/000. ' A C. teen p / I 11. Commercial IH' Yssa,te / 12. Other 0 He. e, ,p Dining Rm. 13. No. of stories / 4 Living Rm. 3 5 crb Bed Rm. 14. Foundation — Full 0 Half 0 Crawl 0 Slab IY 05 17 o Bath 15. Materials — Wood 6d'Cement 0 Other 0 G , 7 o Deck 16. Type of heat — Oil 0 Gas 0 Electric 0 Other a Closed porch 17. Garage — 1 0 2 0 Family Rm. Sun room 18. Swimming pool - Size Garage 19. Storage shed — Size Shed 20. Stove — Wood 0 Coal 0 Alterations/hop, 21. Size of lot: No. of feet front /5",S" i No. of feet rear /9S' No. of feet deep qm ' 22. Size of building. No. of feet front /7 9 If No. of feet side .S'WNo. of feet rear /7 Q 23. Distance from nearest building: Front Ft. side Ft. side Rear 24. Distance back from line or street .2cc! From rear lot line „?So' Side line Ice 25. H.I.C.R. No. �Q / LOT RELEASED BY Signature /lj ��01, . JMA t PLANNING BOARDrf Address r Tref n LL) Ail Date .W?n nlia '. i b. O Von5`71 • BUILDING DEPARTMENT f4. • CONSTRUCTION SUPERVISOR FORM PLEASE PRINT: �//� �/ /�� /� • JOB LOCATION: "29/ 6-.601/ \ 1OsE CLQll_SLE Re1 lih N1/412 r STR�FET VILLAGE OWNER OF PROPERTY: ,4V g,a1 feA/Ty US `� / ` 9 CONSTRUCTION SUPERVISOR: • / /9[J/i All _lr"LLQ 8 �- _tiv- d5/d©d L 7n�Jc0T o �" NAME LICENSE/ NO. PHONE NO. •ADDRESS: 4q( ' ,Cc�A 6-ti • B�,� RL)4: 6C)• ` e m0T� LICENSED DESIGNEE: . ' (IF OTHER,THAN SUPERVISOR) NAMELICENSE 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, RE1OVAL 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 Da!OLITION AS REGULATED BY SECTION 109.1.1 OF THF . 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 ON THE RECORDS OF THE BUILDING DEPA.RT.`ENT. I HAVE READ AND UNDERSTAND MY RESPONSIBILITIES UNDER THE RULES AND REGULATIONS ,FOR LICENSING CC:1 STRUCTION SUPERVISORS IN ACCORDANCE :KITH SECTION 109.1.1 OF THE STATE BUILDING CODE. I UNDERST :; THE CONSTRUCTION INSPECTION PROCEDURES AND THE SPECIFIC INSPECTION AS CALLED FOR BY THE BUILDING OFFICIAL. • INSURANCE COVERAGE: • • I have a current iabllity insurance pcficy or its substantial equivalent which meets the requirements of MdCLth.152 Yes No D If you have checked v_s, please incicate the type c average by checking the aperceriate bcx. 1 • A liability insurance pc:icy pd' Other type of '.acemnity 0 Send 0 CWNES'S INSURANC—c WAIVER: I am aware that the ucensee dces rot have the insurance coverage requirec :y Chapter 152 of the Mass. General Laws, ane :hat my signature cn this permit _tics waives this requirement Check one: Owner- ' Agent 0 S:gratute ct O*ner cr O+,ner s Agent SIGNATURE: BUILDING OFFICIAL APPROVAL: • • fir' __ �• • COMMONWEALTH OF MASSACHUSETTS • DEPARTMENT OF LNDUSTRIAL ACCIDENTS 600 WASHINGTON STREET James Carnpoelt BOSTON, MASSACHUSETTS 02111 • tom nrss onet WORKERS' COMPENSATION INSURANCE AFFIDAVIT • I, %),t N, M0$1217C ci7 (licenseelpermitee) • with a principal place of business/residence an 0291 An PE JR \/ 12 til Y4RM6ule\ 11/41ASsac266t1 / (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. 041tRPR% NofonX �,vs, COWe r --( a -y77agc Insurance Co pany 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. . . a Name of Contractor Insurance Company/Policy Number . _ • Q I am a homeowner performing all the work myself. NOTE:.PIeuC 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(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 Acddents'Office of lnsurance for coverage verification and that failure to secure coverage as required under Section 25A'of MGL 152 can lead to the imposition of 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$100.00 a day against me. �( Signed this #t day of' (0 kat , 19 93 T I • / , _iccr.see Permkrei LicensoriPcrmiror /- - i/ i-'� C'� .I I I IL, I Eia. esev. raw i / -I tacaTlaK Lz_==r'11 �yu,�I _ �KhsTlu[x G^l g B.W :. \- - --- -•- -_ i 'I E.l15r SCPfic r--°-� "I rjtPflL TANK ELL'If. �- -� • �� ---' 'TEE SIZES' �� w' f i F 1 Nt_ET' I G� (G"lir , I o"yoI J Nq_ .J..Ev��v F <v 1 .7 " •, OVitEr t 2-5.4 CO UP Id Dot.IN) — Li T122 — • I ` • . . • . .. - Z.4 Ac. 6 h f, - - - • nit . ♦ '•!u1.7..i•-.v.,.....-. ./04.1„,00---enr-.-..-1... ..- .T." 1,.. .. t • w. ..r ,,;y.Yt.:iVrj•'n`j}- T.,-, l...... _• v • ‘ \ • �_� �' exlSnFab I• - l - /— _ LE/1G11,IIJG .. a . v • d 1 41 i�: r is . 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