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Home My WebLink AboutBLD-93-681 04'•Yq jt •O KFS k 'f t�'o . TOWN OF YARMOUTH q g�93 ` MATTA�M[ , �J 6gt' volt....Jo, Application for a Permit to Build No. UPON FINAL APPROVAL � 47 / MAP 7 LOTG FEE MUST ACCOMPANY THIS APPLICATION. DATE 74 S 19 7 , The undersigned hereby applies for a permit to build /0-3 according to the following specifications 1. Name of property owner °InrlCs + r4ninr Ai+no(er5 (o Tecl. 72TTY9 Address S Lt. n CLO w Gray R4 •QCT yi4 r.,o,,+7-4 2.Name of Architect(if any) Mo ti c Tel. 3. Name of buildera igM e s 5 act. n j c r Address /26 1111/Af Si. /Ar m-I n j 4. License No. 00,3 C a Tel. 36 2 --• 3_71 o 5. Name of Mason A/c AI r Address 6. License No. Tel. 7. Construction address •?C1 W1 ^ 5 Low G rr4 Rc( 6' V Flood YDistrict (Z_as 8. Date of subdivision Approval plain zone G Zone 9. Private dwelling ® Estimated Cost DO NOT WRITE IN THIS SPACE 10. Multi family 0 73 pG r"---- o Type of room No. 11. Commercial 0 -aced-.o d 3b' Kitchen 12. Other ❑ ez-7,0.44..:ye '/' Dining Rm. 13. No. of stories 1 Living Rm. ,y.s�sa + 1' a Bed 14. Foundation — Full 0 HalfCrawl 1 Slab 0 B thRm. 15. Materials — Wood 0 Cement 0 Other IJ Deck 16.Type of heat — Oil 0 Gas 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 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. /o 7 i3t LOT RELEASED BY Signatureti`ler - PLANNING BOARD Address /20 At Date ya-ttry)-ttS:9...cringc, 0-?i7.� . (4U 5 , a 1 r iI is T. e i &e.) 4 �c'esa � � . ._, L " 0 .0 I -1`re14 1-ec.< t . go (' I VVoo a • Sre_P 151 Fiaxi r 1\ 7;s ez3i( ;ex (G 7A S II I Lir Con C.r r r -4_ • CU Ste_ (?crJmv�4C2 ,n� e.n r xis fit n c, S r�� C3 a t< `i-, )3rt PLOT PLAN • FOR LOT # • • Indicate location of garage or accessory building Additions with dashed lines Sewerage disposal (cesspool) ® . Well • 1 (lot ..c0• ft. rear) Abuttor's I Abu Name I Nam Lot # • I • Lot n REAR YARD If this is a If t corner lot, 1 ft. corn write in name wri of street. ® I nam ;; a, .•oth- 0 o sire ro SIDE YARD . SIDE YARD HOUSE• FT FT. r\ • 0 0 Q • a t I Fohf' Site . W S; T BACK . • `A. . . 39 .ft I ` I (lot ft. frontage) • \ / -SCo WI M 5L,0 WV G rra 7 lc( . \ / \ / (NAME OF STREET) • . \ / ' . . .ationr1 / / \ \ \ Supby {�' NN HA- 'Ude r f Phi ��►i '• 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-esisting owner-occupied building containing at least one hut 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. The of Work: I}&N0 VA-1-1 An Est- re700 Address of Work 02 SG Wins 46 C�r, _r ed So Owner Name: CII /}r/yes 'F, / /V FX 4 c ovOt r S Date of Permit Application: ?/r./ 5' I hereby certify that: Registration is not required for the following reason(s): _Work excluded by law _Job under 51,000 Building not owner-occupicd _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: 1 gr/9 5 t9a /O%? , Date Co ractor .'ame Registration No. OR: • Notwithstanding the above notice, I hereby apply for a permit as the owner of the above property: Date Owner Name -• • • COMMONWEALTH OF MASSACHUSETTS o � DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 WASHINGTON STREET James Camvoei, BOSTON, MASSACHUSETTS 02111 • comm:sstoner WORKERS' COMPENSATION INSURANCE AFFIDAVIT • • RZ7I al es • Sprinye-r (Iicensce/perminee) • with a principal place of business/residence at: I aO ' Pi Ai n/ •STre cr 1/9 rrlo u Pi r l- /1 /9- � ' °'& 73 (City/State/Zip) do hereby certify, under the pains and penalties of perjury, that: [) 1 am an employer providing the following workers' compensation coverage for my employees working on this job. • • Insurance Company Policy Number [5Q I am a sole proprietor and have no one working for me. [ 3 I am a sole proprietor, general contractor or homeowner (circle one) and have hircd 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.Pleue 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 status of an employer under the Workers' Compensation Act I understand that : copy of this st::ement will be forwarded to the Department of Industrial Accidents' Office of Insurance for coverage verification and that failure to iecure coverate as required under Section 25A'of MGI.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 5100.00 a dayyaagainst me. �y Signed this v I /n / )�/1 t„ day of //r/ 1s , 19 7 3 icers:_i Pe.^t V Licenso:;Pcrmi or • BUILDING DEPARTMENT • . . , -- • CONSTRUCTION SUPERVISOR FORM LEASE PRINT: ' • n OB LOCATION: c2 sC Wt /I SLOW Gr Y Rd SO y/Ar in0oA NUMBER �/� ) STREET VfLLAGE • , WNER OF ,PROPERTY: ' Chitty,Les -F- .0-NAJ SN 19 ov e� e r s • ONSTRUCTION SUPERVISOR: •1'c {t}-n1 eS S�'r1n / er • 003 aANO. 36'2HO�E NO. • )DRESS: I RC) /via/A) sr. //- hr:noJA ac- T n/9- .. Oa6 -75-- ' . • ICENSED DESIGNEE: • NON [ V ,,, (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 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, RD!OVAL OR DEMOLITION INVOLVING THE STRUCTURAL ELEMENTS OF BUILDING AND STRUCTURES ONLY PURSUANT TO THE STATE BUILDING CODE AND ALL OTHER APPLICABLE LAWS OF THE "01•MONWEALTH, 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 IMMEDIATELY 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 OTHER SECTION OF THESE RULES AND REGULATIONS AND ANY PROCEDURES, AS AMENDED, SHALL 3E SUBJECT 0 REVOCATION OR SUSPENSION OF LICENSE BY THE BOARD. _ . • 2. 16. ALL BUILDING PERM 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 DE!OLITION AS REGULATED BY SECTION 109.1._ OF THE ' . CODE AND THESE RULES AND REGULATIONS. IN THE EVENT THAT SUCH LICENSEE IS NO LONGER SUPERVISING SAID PERSONS, THE WORK SHALL DEMEDIATELY CEASE UNTIL A SUCCESSOR LICENSE HOLDER IS SUBSTITUTED ON THE RECORDS OF THE BUILDING DEPARTMENT. I HAVE READ AND UNDERSTAND MY RESPONSIBILITIES UNDER THE RULES AND REGULATIONS .FOR LICENSING CC' STRUCTION SUPERVISORS IN ACCORDANCE :Ciid SECTION 109.1.1 OF THE STATE BUILDING CODE. I UNDERSTI: THE CONSTRUCTION INSPECTION PROCEDURES AND THE SPECIFIC INSPECTION AS CALLED FOR BY THE BUILDIN OFFICIAL. . INSURANCE COVERAGE: • I have a current b:lity insurance policy a s substantial equivalent which meets the req;:irements ct !dC1 th.152 Yes E No D It ycu have checked_ please inciczte the type c average by checking the agcrcoriate box. A liability insurance pc:icy 7 Other type et '.ticernnity 0 8cnd 0 • CNN ER 2 INSURANCZ WAIVER: I an ewer_ that the rc_.^.see deet rot ",:•P the incu::ac_ covert:,^e rec_:rec Chapter 152 ct the !da--. Gene._: !._ws. an.. ,..at my z:: -:ure cn ,n:s"pe.m;: -c :.canon waxes t..is requirerrc..- . Checa'cr.e: C'nnerO A-yen: D 5.^yna:ra et ' Peer s�Ay2r11 BUILDING PERMIT APPLICATION SIGN OFF APPLICANT: BUILDING PERMIT 1/: ADDRESS: TELE. NO, : ' . DATE FILED; BLDG. SITE LOCATION: MAP/1: LOU: THE FOLLOWING INFORMATION OUTLINES THE PROCEDURAL STEPS REQUIRED TO OBTAIN A PERMIT TO BUILD, ALTER, OR ADD TO A STRUCTURE WITHIN THE TOWN OF YARMOUTH. THE BUILDING DEPARTMENT WILL DETER- MINE COMPLIANCE TO THE FOLLOWING (A) ZONING REQUIREMENTS (B) HISTORICAL DISTRICTS (C) FLOOD PLAINS ZONING. THE BUILDING DEPARTMENT WILL BE RESPONSIBLE FOR ASSISTING THE APPLICANT THOUGH THE FOLLOWING DEPARTMENTS: RESIDENTIAL AND/OR COMMERCIAL BUILDING WATER DEPARTMENT: DETERMINES COMPLIANCE OF WATER AVAILABILITY. ENGINEERING DEPARTMENT: DETERMINES COMPLIANCE FOR PARKING AND DRAINAGE. CONSERVATION COMMISSION: DETERMINES COMPLIANCE TO WETLANDS ACTS, I.E. : IF LOT(S) BORDER ANY TYPE OF WETLANDS, STREAMS, PONDS, RIVERS, OCEANS, BOGS, BAYS, MARSH LAND, ETC. HEALTH DEPARTMENT: DETERMINES COMPLIANCE TO STATE AND TOWN REGULATIONS, I.E.: REQUIRE- MENTS FOR SEPTAGE DISPOSAL AND OTHER PUBLIC HEALTH ACTIVITIES. FIRE DEPARTMENT: DETERMINES COMPLIANCE TO STATE AND TOWN REQUIREMENTS FOR PERSONAL SAFETY,, PROPERTY PROTECTION, I.E. , SMOKE DETECTORS, SPRINKLER SYSTEMS, ETC. THE FOLLOWING DEPARTMENTS MUST SIGN OFF, IN THE RESPECTIVE ORDER, PRIOR TO BUILDING INSPECTOR ISSUING THE REQUIRED BUILDING PERMIT: REVIEWED BY: 1. WATER DEPARTMENT - DATE: N/A: 2. ENGINEERING DEPARTMENT: DATE: - - • - N/A: 3. CONSERVATION: DATE: N/A: 4. HEALTH DEPARTMENT DATE: N/A: INDUSTRIAL AND/OR COMMERCIAL PERMITS 5. WIRING INSPECTOR: DATE: N/A: 6. PLUMBING INSPECTOR: DATE: N/A: 7. FIRE DEPARTMENT: DATE: N/A: • PLEASE NOTE . • ALL STUMPS AND/OR BRUSH MUST BE DISPOSED OF AT AN APPROVED SITE. A SIGNED RECEIPT FROM THE DISPOSAL SITE MUST BE SUBMITTED TO THE BUILDING DEPARTMENT PRIOR TO ISSUANCE OF THE BUILDING PERMIT. COMMENTS: BLM/89