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Home My WebLink AboutBLD-93-680 ` / -OF•YAk ' - oKFeb) 4- sr o, TOWN OF YARMOUTHcffibl • CMECS a. ,, MATTA„ Application for a Permit to Build No. G ,p UPON FINAL APPROVAL A' clJg 93 \ MAP -1.3 LOT 13 gr FEE MUST ACCOMPANY THIS APPLICATION. \ DATE 1-'�'r 19 9,1 The undersigned hereby applies for a permit to build according to the following specifics 'ons \1. Name of property owner / it.C,s CA/Ws Tel. 775ti-1±7 \Address Zi 1544-O'I,aK tWE, 1,t,,nucf rt 2.Name of Architect(if any) Tel. 1 3. Name of builder sei-r Address 4. License No. - Tel. 5. Name of Mason Address 6. License No. Tel. \ 7. Construction address Z7 /3a9--0-2,,0W L,owc 41.)6e.4euri✓" Flood District 8. Date of subdivision Approval plain zone Zone 9. Private dwellin9N Estimated Cost DO NOT WRITE IN THIS SPACE Type of room No. 10. Multi family 0 \ "700. �� a,as 11. Commercial 0 `R°OF �� Kitchen c9 DrQ. I !-,r�c�12 12. Other 0 CgetK VE0-) 1 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 Deck _ 16. Type of heat — OH 0 Gas 0 Electric 0 Other ❑ Closed porch 17. Garage — 1 0 2 ❑ Family Rm. Sun room 18. Swimming pool - Size Garage 19. Storage shed — SizeShed 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 I / / Side line 25. H.I.C.R. No. i LOT RELEASED BY '\Signature Zi PLANNING BOARD , Address r Js." Cr` I/Ake L,4.,v&- Date Cu •M•o-„dE��- ` ' =- COMMONWEALTH OF MASSACHUSETTS 3 . DEPARTMENT OF INDUSTRIAL ACCIDENTS �' 600 WASHINGTON STREET James J CamDoei, BOSTON, MASSACHUSETTS 02111 • Commrss,oner WORKERS COMPENSATION INSURANCE AFFIDAVIT \ I, /7`4i2,4/s GA' VO.S (licensee/perminee) • with a principal place of business/residence an 2/ nets -O '-vK two-- ai.24,e nd€Ta; t/441-l. 026?) (Ciry/Sate/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 o 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. / v NOTE_.Please be aware that while homeowners who empioy 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 horneowoer 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 Aeddents'Office of Insurance 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 consisohg 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 d9r j / day of _Ct-712— , 19 7S` r: .iter!,. _ I License./P trmr:.__ , Linso r;P:rmirro Suggested Affidavit for Home Improvement Contractor Permit Application For Office list Only NAME OF CITY/TOWN Permit No. Date AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application MGL e.142A requires that the"reconstruction.alteration.renovation,renair.modernization,conversion.inprovement,removal,demolition. orconstruction of an addition to any prettisting owneroccuoied building containingat least one but not more I ban four dwelling units....or to structures which are adjacent to such residence or building"be done by registered contractors,with certain aceptions,along with other requirements. Type of Work: , t-,eacP'rt/6_. 9 EmCost4goo, Address of Work Z/ n0/3 -6^ ZNA-- A.vo, C(j.y�j�,ya✓?�7` \Owner Name: gi22.. S 64/71)s • Date of Permit Application: 8 Sept' /t, 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: Date Contractor Name Registration No. OR: . • Notwithstanding the above n. ice, I hereby i Iy for a pf ta P .. - of the above property: die 8 SEn7 Qj Date OwnerName /�' TOWN OF YAMOUTH BUILDING DEPARTMENT HOMEOWNER LICENSE EXEMPTION PLEASE PRINT: DATE 8Seer > iell JOB LOCATION 21 /30'3 -O— AIAXC t¢A4 . YA?. +4OU%eat— NUMBER '� STREET ADDRESS SECTION OF,TOWN "IIOMEOWNER" jC}/2i2�S C//O,v?V5 775-- 9s'f y 3 7U-c/br// NAME HOME PHONE WORK PHONE • PRESENT MAILING ADRESS Z / /44 — U— /NA' LAA'1 lei•>%Cs-vdcP7" ./!?4s.r 006 7[3 CITE OR TOWN STATE ZIP CODE THE CURRENT EXEMPTION FOR "HOMEOWNER" WAS EXTENDED TO INCLUDE OWNER—OCCUPIED DWELLINGS OF SIX UNITS OR LESS AND TO ALLOW SUCH HOMEOWNERS TO ENGAGE AN IN— DIVIDUAL FOR HIRE WUO DOES NOT POSSESS A LICENSE, PROVIDED THAT DIE OWNER • ACTS AS SUPERVISOR. (STATE BUILDING CODE SECTION 109.1.1) • DEFINITION OF HOMEOWNER: PERSON(S) WHO OWNS A PARCEL OF LAND ON WHICH HE/SUE RESIDES OR INTENDS TO RE— SIDE, ON WHICH THERE IS, OR IS INTENDED TO BE A ONE TO SIX FAMILY DWELLING, ATTACHED OR DETACHED STRUCTURES ACCESSORY TO SUCH USE AND/OR FARM STRUCTURES. • A PERSON WHO CONSTRUCTS MORE TITAN ONE HOME IN A TWO—YEAR PERIOD SHALL NOT BE CONSIDERED A HOMEOWNER. SUCH "HOMEOWNER" SHALL SUBMIT TO 111E BUILDING OFFICIAL, ON A FORM ACCEPTABLE TO THE BUILDING OFFICIAL, THAT HE/SITE SHALL BE RESPONSIBLE FOR ALL SUCH WORK PERFORMED UNDER THE BUILDING PERMIT. (SECTION 109.1.1) THE UNDERSIGNED "HOMEOWNER" ASSUMES RESPONSIBILITY FOR COMPLIANCE WITH TUE STATE BUILDING CODE AND OTHER APPLICABLE CODES, BY—LAWS, RULES AND REGULATIONS. DIE UNDERSIGNED "HOMEOWNER" CERTIFIES 1T HE/SHE UNDERSTANDS TUE TOWN OF YARMOUTH BUILDING DEPARTMENT MINIMUM INSPECT • ' PROCEDURES AND REQUIREMENTS AND THAT RE/SHE WILL COMPLY WITH SAID PROCEDURESj REQU y(i S U`,iS. el —i iHOYIOWNER'S SIGNATURE -An?• APPROVAL OF BUILDING OFFICIAL NOTE: THREE FAMILY DWELLINGS 35,000 CUBIC FEET, OR LARGER, WILL BE REQUIRED TO COMPLY WITH STATE BUILDING CODE SECTION 127.0, CONSTRUCTION CONTROL. INSURANCE COVERAGE: I have a current lability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No 0 If you have checked ves, please indicate the type coverage by checking the appropriate box. A liabil;:y Insurance pc:icy 0 Cther type cf indemnity 0 Bond 0 OWNER'S INSURANCE YAIER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 cf the Macs. General Laws, and that my signature cn this perm.. application waives this requirement. Check cr.c: Owner ❑ Agent ri _.y'a:.:^_ c: C'*ter cr C'c..er s A:art - ___ _