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Home My WebLink AboutBLD-93-677 •1= vrr h. o TOWN OF YARMOUTH pi� y { \• cc., MATTAEME 5 � .4 , t; Application for a Permit to Build No. 6 77 UPON FINAL APPROVAL 0 I"3 13 MAP - 1 z 0 LOT V— W FEE MUST ACCOMPANY THIS APPLICATION. DATE 319 93 The undersigned hereby applies for a permit to build ! 3 3 according to the following specifications 1. Name of property owner AA' i<>/5P-Az . t C/A,fJSOr✓ Tel.3GZ--3313' Address rye lmdtA-z- ear )/ einany wsr 2.Name of Architect(if any) / / Tel. a Name of builder Jet in/ _LA/ __win,• __win, Address /6 ys-/V n'✓,4 C;e ruin ba-v 4. License No. 0,16/A Tel. 4/28-Iner 5. Name of Mason Address -- 6. License No. r Tel. 7. Construction address 9f lod.✓a'Ac -/4j� ien761 FI od District a Date of subdivision Approval plain zone Zone Jt yO 9. Private dwelling 0 Estimated Cost NOT WRITE IN THIS SoomE si 10. Multi family ❑ 12$0D t Type of room No. 11. Commercial 0 .ecbc - ?Mazza 1 Kitche 12. Other ❑ �e�� - " �� Dining Rm. 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 0 rn / _ Deck 16. Type of heat — Oil 0 Gas 0 Electric 0 Other 0 •�`! Closed porch n 17. Garage — 1 0 2 ❑ and �"`°�• Sun room Family Rm. 18. Swimming pool - Size Garage 19. Storage shed — Size Shed 2a 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. 7. 0?9`O LOT RELEASED BY Signature 2 �A� r PLANNING BOARD Address /6 9-r- // A/ Date r:7-07-22/7- >71/9- D26,1°,1— COMMONWEALTH OF MASSACHUSETTS DEPAXPeT OF NDUSTRIALACCIDENTS 1 600 WASHINGTON STREET ,a s J �_�_,; BOSTON, MrLSSACHU TS 02111 • mor.:-•ss•c-e• WORnRS' COMPENSATIONLNSURANCEAFFIDAVIT • (licersc/pc. ' cc) • with a principal place of business/residenceus/ at /o 9f /Valereu/�✓ it'a ( 7./ii (City/Sratcriip) 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. • (951/82-/y C'0022Se/ 4' 74/ Insurance Company Pea:Number [) 1 an a sole proprietor and have no one working for me. [) I a sole proprietor. general contraeor or homeowner (c::_:one) and have hired the contractors listed b:::•- who have the following workers' cempcnsazion insurance poiider. Name of Contractor Ince nc: Company/Policy Number Name of Contractor : Insace Company/Policy Number Name of Contractor In:_ace Company/Policy Number 0 1 arra a homeowner performing all the work myself. KC'-.• Please be awue that while hor now:err who employpc:;ors to ca maintenance,cons:rueioc or repair work or. a dwci:_:cf not more that three utiu it which the homnwae:also residue:::the grounds appurtenant thereto are not gene:a_y considered to be employers sande:the Workers' Compensation Act(GL C.15:.sr_- 1(5)). application by a homeowner fora limns: or p::rain ray evident:the legal stems of as employer under the Workers'Ct=xnsation Act 1 u..-.r.a.- that a ter cf this stat:tent will be fcrw...:.: :o the Acidents'Office of ltsurae for cv.. . ve:i5c: cr.and that fellu :to scour:cave.i:as required under Section 25:::f MCL 152 can lead to the imposition of m1.-.al pen sisdnz line line of up to 51 500.00 em.c'or in prso nr..en:of u: to one y-._and cv".s pcnai_a in the form of a S:o.Work Order t_: fin:of S l C ^0: dey az:irs:me. Sir- - . ... day of , 19 9 S • • / . At" .-s. .. License:.-.:mina:: Lic::s::iPe:mi .or • Suggested Affidavit for Home Improvement Contractor Permit Application • • For Office Use Only. NAME OF CITY/TOWN Permit No. \ os Date ar AFFIDAVIT Ilome Improvement Contractor Law • Supplement to Permit Application MGLc.I42A requires that the"reconstruction.alteration.renovation.reaair,moderniration.conversion.inprovement,removal.demolition. or construction of an addition to any preciisung owneroccuoied building containing at least one but not more than four dwelling units....or to structures which are adjacent to such residence or building"be done by registered contractors,with certain exceptions,along with other requirements. cid Type of Work: STR!•9 cat– �6e�o�� Est. Cost ygoo (v - Address of Work -Yr / t/w,,1,� 44-7 Owner Name: Som Date of Permit Application: 5'— 3 -- 3 • I hereby certify that: Registration is not required for the following rcason(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 MGL e. 142A Signed under penalties of perjury: I hereby apply for a permit taas the agent of the owner: er Date Contractor Name / Registration No. OR: Notwithstanding the above notice, I hereby apply for a permit as the owner of the above property: Date On net. Name BUILDING DEPARTMENT • 1' --- _- —CONSTRUCTION SUPERVISOR FORM LEASE PRINT: • - - OB LOCATION: 44'. 6104/ �olleor 21204 NUMBER STREET VILLAGE . WNER OF .PROPERTY: �a� �u/��✓Son� ONSTRUCTION SUPERVISOR: • i :' O yG/A 89-CY:7 � ////I/ NAME • LICENSE NO. - PHONE NO. • Mf )DRESS: /G r :d../ /ATD . i% 11 02 Gr ICENSED DESIGNEE: (IF OTHER.THAN SUPERVISOR) NAME LICENSE 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 • • 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 LAWS OF THE ' O21ONWEALTH, 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 Ii4-!EDIATELY 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 BE 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 isE CONSTRUCTION SUPERVISOR WHO IS TO SUPERVISE THOSE PERSONS ENGAGED IN CONSTRUCTION, RECON— SLRUCTION, ALTERATION, REPAIR, REMOVAL OF DE_`!OLITION AS REGULATED BY SECTION 109.1.. OF THE ' . ODE AND THESE RULES AND REGULATIONS. IN THE EVENT THAT SUCH LICENSEE IS NO LONGER SUPERVISING SAID PERSONS, THE WORK SHALL DI EDIyTELY CEASE UNTIL A SUCCESSOR LICENSE HOLDER IS UBSTITUTED N THE RECORDS OF THE BUILDING DEPA_R.:.ENT. I HAVE READ AND UNDERSTAND MY RESPONSIBILITIES UNDER THE RULES AND REGULATIONS .FOR LICENSING CC' STRUCTION SUPERVISORS IN ACCORDANCE WITH SECTION 109.1.1 OF THE STATE BUILDING CODE. I UNDERST _ LE CONSTRUCTION INSPECTION PROCEDURES AND THE SPECIFIC INSPECTION AS CALLED FOR BY TEE BUILDIN OFFICIAL. INSURANCE COVERAGE: • • I have a c_:rent liablity insurance pair/ a its substantial eppivalent which meets the requirements cf MGLth.152 Yes No 0 If ycu have checked ves. plea__ inciczte the type . ..erase by checking the ___.__ria._ box. Y • A liab ity insurance pc:icy r? Cher type cf '..cemnity 0 Ecnd 0 CWHErVS INSURANCE WAIVER: I am aware that the ::censee do-- ^ct „ ., P the insurance . vera;ec_a reet C:-.zaer 152c: the !.SC_:• General Laws. are ...at my sic .. . r e cn .... perm:: _:a.. _,cn was es this rep::ire:ten: - Checx che: C.sner0 Agent S.';na:ura ei C•.ner Cr pwcer •gam ..