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HomeMy WebLinkAboutBLD-93-683 ;` Yq mk -w/ /fr/P3 `� k6P.;ilr0 . TOWN OF YARMOUTH o(C a`l'' 9/r/j f `N " .$'s1/4„ $ Application for a Permit to Build No. &�3 -' UPON FINAL APPROVAL ,V/' " 93 MAP LOT FEE MUST ACCOMPANY THIS APPLICATION. DATE ,571 19 9 3 The undersigned hereby applies for a permit to build 9c� _ ` according to the following specifications / 3 1. Name of property owner Merit Leurw e. / el. 77J-775� Address a itlecidoco 1roD,f! RA W "f4rnouTh . 2.Name ofArchitect ifany) ef.4 Tel. 3. Name ofbuilder2ruce J eWQ-C I Address .I eQb/ 28' Ala eWSAt/6 4. License No. OOg70'-3 Tel. q aD - a- 4,01 5. Name of Mason Wel- Address 6. License No. Tel. 7. Construction address .2 /49/7/9b6iD er-e/2 �1 IV\I 4 ' Flood District C 8. Date of subdivision A proval plain zone C- Zone / %�� 9. Private dwelling Estimated Cost O-NQT WRITE IN THIS SPACE Type f room No. 10. Multi family ❑ e'7) ` ( , ,_„/�. 11. Commercial 0 5TA/P spire 4 Kitchen �l//jj�� 12. Other ❑ ( gn_ Leh Dining Rm. 13. No. of stories l Living Rm. �fiu-d 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 - 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 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. Na of feet front No. of feet side Na 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. tba-(a i r aikti_52LOT RELEASED BY Signature 4 i'• ' s PLANNING BOARD Address 911 W� X22. 1 , Date PittsGrnNS Avils • • • k - 7.7 COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF INDUSTRIAL:ACCIDENTS 600 WASHINGTON STREET • James Campoeu BOSTON, MASSACHUSETTS 02111 • Commissioner WORKERS' COMPENSATION INSURANCE AFFIDAVIT • • I, }')ruc cp `2os UM. ( / `1r25 . ) ckM•-Q5 A Co (licensee/permince) • with a principal place of business/residence at: Cl-( carom,, f cc. Mair Ss rvos ifs Pc, . ())-(phii: • (City/Sate/Zi)l) do hereby certify, under the pains and penalties of perjury, that: 05,00 am an employer providing the following workers' compensation coverage for my employees working on this job. • Itau e %rs t1)S (0AJ — (��n-- 933'I 0(p - 93 Insurance Company Policy Number I am a sok 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: •r•-•••••••••• • • ._ Name of Contractor Insurance Company/Policy Number.. . • Name of Contractor Insurance Company/Policy Number • " . • Name of Contractor • Insurance Company/Policy Number . 0 I am a homeowner performing all the work myself. NOTE_..Please be aware that while homeowners who employ persons to do maintenance,construction or repairwork 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 homeowoer for a license or permit may evidence the legal sums of an employer under the Workers' Compensation Act. I understand that a copy of this statement will be forwarded to the Department of Industrial Acddenu' Office of Insurance for coverage verification and that failure to secure coverage as required under Section 25A'of.MGL 152 an lead to the imposition of criminal penalties consisong 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. Sicned this714 day of J0{ reivv ✓t , 19 3 A QQ V Licer o:/Pcrmirz • BUILDING DEPARTMENT .CONSTRUCTION SUPERVISOR FORM i LEASE PRINT: ' • �^ f OB LOCATION: a. • J✓I L�Cr,Ql3il) h. _ - 0 ' • • • NUMBER . STREET VILLAGE WNER OF ,PROPERTY: ' /V4,,Q(NO U L..t U (-U { ./ •.ten n 7 • 1.-/ 1, ONSTRUCTION SUPERVISOR:�yyJLJ2 i• ?[I4wa.1. " ©v/fie/ J Tan- a'y(� (�• //� � )) fr_� NAME . ....• : . NO. PHONE NQ. (DRESS: 9Af' WCG�C4ki \1d . ., A9 /IDS ( •L( S . . • ICENSED DESIGNEE: / i ' • 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 . 15.2 THE LICENSE HOLDER SHALL BE RESPONSIBLE TO SUPERVISE THE CONSTRUCTION, RECONSTRUCTION, .TERATION, REPAIR, REMOVAL OR DEMOLITION INVOLVING THE STRUCTURAL ELE.*1ENTS OF BUILDING VD STRUCTURES ONLY PURSUANT TO THE •STATE!BUILDING CODE AND ALL OTHER APPLICABLE LAWS OF THE OiQ1ONWEALTH, 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 IMEDIATELY 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 THER 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 LHE CONSTRUCTION SUPERVISOR' WHO IS TO SUPERVISE THOSE PERSONS ENGAGED IN CONSTRUCTION, RECON- CTRUCTION, ALTERATION, REPAIR, REMOVAL OF DE".OLITION AS REGULATED BY SECTION 109.1.1 OF THE -ODE AND THESE RULES AND REGULATIONS. IN THE EVENT THAT SUCH LICENSEE IS NO• LONGER SUPERVISING +ID PERSONS, THE WORN SHALL 1121.EDIATELY CEASE UNTIL A SUCCESSOR LICENSE HOLDER IS SUBSTITUTED N THE RECORDS OF THE BUILDING DEPARTMENT. I HAVE READ AND UNDERSTAND MY RESPONSIBILITIES UNDER THE RULES AND REGULATIONS .FOR LICENSING Cr:: STRUC.ION 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 BUILDIN OFFICIAL. INSURANCE COVERAGE: • • I have a current ty insurance policy er s substantial equivalent which meets the requirements d MOL h.152 Yes V . No ❑ If you have checked_s, please inciicte the type c:verage by checking the accrccriate box. E+ A liab ity insurance pc Icy 127C , C:her type cf '..cemntty 0 Bond 0 CWNER'., INSURANCE WAIVER: I am away_ that the r:censee dc__ ^. of h,:•P the insure,,__ covera}e rec.:rec _ 152 of h !!a_ . Gene= L••Ns• anc ,n:: my •urc cn pent:: :sc:,ca:icn wares this recciremcr._ �y �f Check One: [ a �yC� C �XY i C'.vr.e. _ Age . �#_.g .re c1 CAne cr 0,.cer s Agent ' Suggested Affidavit for Home Improvement Contractor Permit Application • For Office Use Only NAME OF CITY/I'OWN• Permit No. W /at Dale AFFIDAVIT Home Improvement Con ractor Law • Supplement to Permit Application TrY MGL e.142A requires that the"reconstruction,alteration.renovation,repair,modernization,conversion.inprovemen t,removal.demolition. or construction of an addition to arty preccisunq owner-occupied buddingcontainin1 at least one but not more than four dwelling units....or to structures which are adjacent to suet residence or building"be done py registercd,contractors;wuh certain exceptions,along with other requirements. f, )/�^% �Y.- eiNk.J sr. • ( The of Work: 1R' h4<'0 J f./Air/ 170-f1 f t•,/�ji1 R rl s,/; : 1j/ Es s Est. Cost 9172e Address of Work <9 M ec l o .ilrrocie.. , U) >yaeitvav / h- ill Owner Name?f/� ✓ TU/!J C e (�1`r{J�2 •r� . • Te •`_ Date of Permit Application: f/ 7/ / 3 I hereby certify that: .{ ? ,J non- Registration is not required foftfe following reason(s): ' _Work excluded by law _Job under 51,000,r• <• <, Building not.owner:oc<picd _Owner pulling owri permit _Other (specify) • Notice is hereby given that: f 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: RirtiC .P A7eS12-w&i ( /Q 19-(01C D to Contractor Name Registration No. M v OR: • gt Notwithstanding the above notice, I hereby apply for a permit as the owner of the above property: •1 Date X5,5 % -f 7 Owner Name f�r J i/ • ? ' ,,.,_ f ti .