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Home My WebLink AboutBLD-93-675 f .*�= ~� rho TOWN OF YARMOUTH 0�1 C ` MATTAGMC 5 "4 I 6 7� �,4e. i Application for a Permit to Build No. UPON FINAL APPROVAL � 1-3 J MAP 67 LOT C '/60 FEE MUST ACCOMPANY THIS APPLICATION. DATE //-�/ 19 9.3 The undersigned hereby applies for a permit o build 9/thrs according to the following specifications e ", c/C3 a/S VI' Name of property owner Dick Qe2(/ / SS Tel. Address 0 /'1 1P!Nn lIl Q/Look 2.Name ofArchitect(ifany) / o Tel. U3. Name of builder L�Ruc2. A .)'LLc C4 5 Address of S1&J/N s om e Er 33 90/2, 4. License No.4 t•tt Tel. 7 9,-FP/0 5. Name of Mason Address 6.�License No. Tel. Y!Construction address =---""""rniS '• -4/L sari. .4. 1 Ilit Flood District a Date of subdivision Approval ` plain zone Zone 9. Private dwelling 0 Estimated Cost DO NOT WRITE IN THIS SPACE o a o m Type of room No. a 10. Multi family 0 F 11. Commercial ❑ Stui,d 1e -/) Kitchen 12. Other ❑ �.�x-fo /cS tao Dining Rm. /'per 700 . LivingRm. 13. No. of stories G`�' yBed Rm. 14. Foundation — Full 0 Half 0 Crawl 0 Slab 0 ----Le—,v Or- 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 No -2 Shed 20. Stove — Wood 0 Coal 0 tit ; 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. 'd 0-6 6&6— tz LOT RELEASED BY . I°gar/2 Signature Z5jn Ce- • "< PLANNING BOARD \ Address Date , 1 Suggested Affidavit for Home Improvement Contractor Permit Application • For Office Use only NAME OF CITY/TOWN Permit No. Dale AFFIDAVIT Home Improvement Contractor Law • Supplement to Permit Application • • ?AUL c.142A requires that the"recOnstruction.alteration.renovation.renair,modernization.conversion.inprovement,removal.demolition. or construction of an addition to any pre-cristing owner-occunied building containing at least one but not more than four duelling units....or to structures which are adjacent to such residence or budding"be done by registered contractors,with certain exceptions,along with other requirements. Type of Work: 5 ( 1211n 4, (Ktz60c Est. Cost aeoo - Address ofWork [Z Le,IM(pf )l ( 6Poo k est Owner Name: G� Date of Permit Application: //3/ J^� I hereby certify that: Registration is not required for the following reason(s): - _Work excluded by law Job under $1,000 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, I42A. Signed under penalties of perjury: I hereby apply for a permit as the agent of the owner: 9/3/93 32uce wNLc245e /oy.2y3 Dthe 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 BUILDING DEPARTMENT ._._ __:=:.CONSTRUCTION SUPERVISOR FORM LEASE PRINT: _' `� � l (�_ D' 'f' OB LOCATION: I ` • COI MQ 1 Igil G ROO�C R. • SG 2 r NUMBER o p STREET VILLAGE WNER OF PROPERTY: O(�� OepIn�1nol Spp laza. ' ! � p ONSTRUCTION SUPERVISOR: l32UCe rucc-Hee•' . no l 378-378 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 COM2LETELY 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, .TERATION, REPAIR, RE!OVAL OR DEMOLITION INVOLVING THE STRUCTURAL ELE*IENTS OF BUILDING ND STRUCTURES ONLY PURSUANT TO THE STATE BUILDING CODE AND ALL OTHER APPLICABLE LAWS 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. .15.3 THE LICENSE HOLDER SHALL Ii2IEDIATELY NOTIFY THE BUILDING OFFICIAL IN WRITING OF THE ISCOVERY OF ANY VIOLATIONS WHICH ARE COVERED BY THE BUILDING PERMIT. . 15. 4 ANY LICENSEE WHO SHALL WILLFULLY VIOLATE SUBSECTIONS 2.15.1, 2.15.2 OR 2.15.3 OR ANY THEP, SECTION OF THESE RULES AND REGULATIONS AND ANY PROCEDURES, AS AMENDED, SHALL 3E SUBJECT 0 REVOCATION OR SUSPENSION OF LICENSE BY THE BOARD. .16. ALL BUILDING PERMIT APPLICATIONS SHALL CONTAIN THE NAME, SIGNATURE AND LICENSE NUMBER OF .EE CONSTRUCTION SUPERVISOR WHO IS TO SUPERVISE THOSE PERSONS ENGAGED IN CONSTRUCTION, RECON- TRUCTION, ALTERATION, REPAIR, REMOVAL OF DEMOLITION AS. REGULATED BY SECTION 109.1.: OF THE ' . ODE AND THESE RULES AND REGULATIONS. IN THE EVENT TeL T SUCH LICENSEE IS NO LONGER SUPERVISING AID PERSONS, THE WORK SHALL IMEDIATELY CEASE UNTIL A SUCCESSOR LICENSE HOLDER IS UBSTITUTED 'N THE RECORDS OF THE BUILDING DEP R ENT. 1 HAVE READ AND UNDERSTAND MY RESPONSIBILITIES UNDER THE RULES AND REGULATIONS .FOR _ICENSING CC TRUCTION SUPERVISORS IN ACCORDANCE WITH SECTION 109.1.1 OF THE STATE BUILDING CODE. I UNDERSTI_ _E= CONSTRUCTION INSPECTION PROCEDURES AND THE SPECIFIC INSPECTION AS CALLED FOR BY THE BUILDIN FFICIAL. ' INSURANCE CCVERACE: I have a current b:tihy insurance pc8cy cr its substantial equivalent which meets the requirements ct MGA th.152 Yes r Na ❑ It you have checked_. ;,tease incite the tyre c;veragc by checking the a__._cnate bcx. A liability insurance pc:icy err Cher type of :.,eemn ty 0 8cnd 0 CWHE;.•„ INSURANCE WAIVER: I am aware that the licensee de__ ^et !•-mP the in_ u ccvercge re :rec C•`a::et 152 at the !Aa_:. Gen_rj L-ws. ane ,. . at my stc _:urc on tn:a permit _a-:i:_:cn waiyes this requiter..._ . _ J (�/� Check ene: . r 7e„,e'Ci(9"� ?qui,. C•.�ner`: Agent G ...^y.:azera Cl ltwner Cr(..)..ret 3 A., N • • • ' "'' COMMONWEALTH OF MASSACHUSETTS P.• • DEIAR:MEICOFINDUSTRIAL:ACCIDENTS 600 WASHINGTON STREET James Car ooei, BOSTON, MASSACHUSETTS 02111 • Commissioner WORKERS' COMPENSATION INSURANCE AFFIDAVIT • I (licensee/permittee) • with a principal place of business/residence at: (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 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 • Name of Contractor Insurance Company/Policy Number 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 dwelling.of not more than three uhlu 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 : copy of this statement will be forwarded to the Department of Industrial Aeddenrs' Office of Insure`for coverage veri:ic:ion and that failure to;entire coverage as required under Section 25A'of MGL.152 can lead to the impoiition of criminal penalties consisting of a Fine of up to $1500.00 and/or imprisonment of up to one year and dvii penalties in_the form of a Stop Work Order and a fine of S 100.00 a day against me. 3 Signed this �,Uc�,�//G day off��Ql� , 19 7? _icens:e Perrnr:__• Licensori. :rmrtto.