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Home My WebLink AboutBLD-93-678 ,--ot.Y4 .. o KFS✓ �s, s 4410, TOWN OF YARMOUTH Wu 0 t y 'i� MATTACME S �1 • / eCk.....),6cei Application for a Permit to Build Na. UPON FINAL APPROVAL ,� 11 q MAP a 7 LOT C G/ FEE MUST ACCOMPANY THIS APPLICATION. DATE The undersigned hereby applies for a permit to build 9 7 93 according to the following specifications ��, 1. Name of property owner '°11. Ce o... 7/7A1. '778//i Address �'-2 /Scx -e--t.'y .(, n. . uJi - 2. ameofArchitect(ifanp Tel. Name of builder ,-.7.1t 4 4 ��// .c nn- Address aq i lam2&„,„, r114 4. License No. Tel. 5. Name of Mason Address 6. License No. Tel. 7. Construction address 58 651 -� i- .‘ew f y Flood District � cfd 8. Date of subdivision Approval plain zone �� Zone 9. Private dwelling 0 Estimated Cost DO NOT WRITE IN THIS SPACE Type of room No. 4 10. Multi family 0 O 3 0, oo t t I' 4got f R�PtJroo 11. Commercial 0 ii ithezi, PS/0 /tknL ' Kitchen 12. Other z Dining Rm. 13. No. of stories Living Rm. Bed Rm. 14. Foundation — Full 0 Half 0 awl ❑ Slab ❑ Bath 15. Materials — Wood 0 Cement 0 Other 0 15r; (re Deck 16.Type of heat — Oil 0 Gas 0 Electric 0 Other 0 . Closed porch 17. Garage — 1 0 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 lot line Side line 25. H.I.C.R. No. /0 .2 3 as ,�/f LOT RELEASED BY Signature CSL w,, f79Zr"4-2 PLANNING BOARD Address 0??/ G•-0 _,.-,4 Dater/ tA,,A.,., --,.2.4/6 at, O Age 9445 ,`mac • "1 ` ' _ . COMMONWEALTH OF MASSACHUSETTS DEI'AR MEN'T OF L*IDUSTRIAL ACCIDENTS • 600 WASHINGTON STREET • eames Camooeu BOSTON, MASSACHUSETTS 0211.1 . ...0 ssroner WORKERS' COMPENSATION INSURANCE AFFIDAVIT • I. rti..CrctiLl : (licentee/perminee) • with a principal place of business/residence an — = 099/ CaAtigt„,a1J cele 4' 0-----ic_te-- G a6-0/ (City State/Zip) do hereby certify, under the pains and penalties of perjury, that: (,rj/ I am an employer providing the following workers' compensation coverage for my employees working on this job. Co-67-kt.4.47,- 04.42., Ce--- C Cs L 0 • Insurance Company Policy Number ( ] I am a sole proprietor and have no one working for me. • ( ] I am a sole proprietor,genera] 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 - . . • o 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 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 suras 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 Insurande for overage verification and that failure to secure 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 civil penalties in the form of Stop Work Order and a fine of S100.00 a day against me. Signed this (el + day of 61:tz7A. 9 , 19 9 LiceaseeiPermirct Licensor/Permir.or Suggested Affidavit for Home Improvement Contractor Permit Application - For Office Use Only NAME OF CITY/TOWN Permit No. Date AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application MGL c.142A requires that the"reconstruction.alteration.renovation.repair,modernization.conversion.inprovement,removal.demolition. or construction of an addition to any pre-existing owner-occupied buildingcontaimne at least one but not more than tour 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. Type of Work: ` %tn Est. Cost 0 ODd Address of Work orh a a t Owner Name: y Celnaar" Date of Permit Application: c,e_ '1- '7/ /Fy,3 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 142A. Signed under penalties of perjury: I hereby apply for a permit as the agent of the owner: .Q 3 X4.2 Dte a 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 . • . CONSTRUCTION SUPERVISOR FORM ! ' • - • • ' PLEASE PRINT: . , . JOB LOCATION: •• 5 . . • '. .. • w /-� R/k .. ... • NUMBER /�' STREET VILLAGE .• OWNER OF PROPERTY: ' Y/"/it •• • CONSTRUCTION SUPERVISOR: i° /a • 77isa6c' . NAME .. LICENSE NO. • . PHONE NO. . ADDRESS: d ! / Ci„,_249.,.r„rrna •e..L-r ' • • • AA. -ti - €r-1a•. O.:261i•/' • LICENSED DESIGNEE: • (IF OTHER_THAN SUPERVISOR) NAME LICENSE 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 STAT 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, REMOVAL OR DEMOLIIION INVOLVING THE STRUCTURAL ELEMENTS OF BUILDING AND STRUCTURES ONLY PURSUANT TO THE STATE BUILDING CODE AND ALL OTHER APPLICABLE LAWS OF THE CO?210WWEALTH, 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 I:M_EDLITELY NOTIFY THE BUILDING OFFFICIAL 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 BE SUBJECT TO REVOCATION OR SUSPENSION OF LICENSE BY THE BOARD. , . • • ' 2.16. ALL BUILDING PERMIT APPLICATIO:;S SHALL CONTAIN THE NAME, SIGNATURE AND LICENSE NUMBER OF THE CONSTRUCTION SUPERVISOR WHO IS TO SUPERVISE THOSE PERSONS ENGAGED IN CONSTRUCTION, RECON- STRUCIION,• ALTERATION, REPAIR, REMOVAL OF DE1e.OLITION AS REGULATED BY SECTION 109.1.: OF TEE CODE AND THESE RULES AND REGULATIONS. IN THE EVENT THAT SUCH LICENSEE IS NO LONGER SUPERVISON SAID PERSONS, THE WORK SHALL IMMEDIATELY CEASE UNTIL A SUCCESSOR LICENSE HOLDER IS SUBSTITUTED ON THE RECORDS OF TEE BUILDING DEPARTMENT. . '. ' '. ' ' • ' I HAVE READ AND UNDERSTAND MY RESPONSIBILITIES UNDER THE RULES AND REGULATIONS .FOR LICENSING C STRUCTICN SUPERVISORS IN ACCORDANCE WITH SECTION 109.1.1 OF THE STATE BUILDING CODE. I UNDERST THE CONSTRUCTION INSPECTION PROCEDURES AND THE SPECIFIC INSPECTION AS CALLED FOR BY THE BUILDI OFFICIAL. • INSURANCECOVERAGE: . . - .. I have a ccrreViab:'ity insurance pclicy cr tts sub;tntiai eq_ivalent which meet the req..re^eats et 'cith.152 Yee No ❑ If ycu have checked v_• -.tea irci z'e the ;pe c;very: by check,ng the a;c..p• riate bcz, ' A liab ity in;arance pc:LT/ ❑ Cher type of :.iderrentty 0 ecnd ❑• �... CWNER'S 1NSURANC-z WAVER:I am aware that the rc_nsee d:__ -ct •_v- the in;trn-_ c:t - • e r mec C`ap.:r152 cf the Ma__. Gere: Lws, arc that my ;t^r .:IC Cr , .. perm:: .--••__..cn wa e; n:: re:uirenen_C` cc cne: • C.vrer_ Agent Q .ars:::act .._ner e:U.rer:_;enc SIGNATURE( °7vfc.Hr BUILDING OFFICIAL APPROVAL: