HomeMy WebLinkAboutBLD-93-686 613/4k; Gni ' `dy/93\
k . L, o TOWN OF YARMOUTH orr� g�Z� o
: 0 �•Y 1 y
H :Lia! ` 5 $J Application for a Permit to Build No. 6 P6
< ..to. PP Oohs
UPON FINAL APPROVAL ,ot/� / ��dMAP 2 S LOT/ 1—I
FEE MUST ACCOMPANY THIS APPLICATION. DATE � T9 *9-3
The undersigned hereby applies for a permit to build 9/10)43
according to the following specifications drum
I_ ` r^ 91k470
1. Name of property owner rittyrile-1 c C dr m Tel.
Address2 ). t rAr , (l-�
2.Name of Architect(if any) Tel.
3. Name of builderN14D ` r�O0Pt cwA .rfsDa Z
D fth lon a • .
4. License No. a-(S(•2).S- TeL �� PJ76O '(45-00 S .Bernis
5. Name of Mason Address
6. License No. C � —' Tel. ( /
7. Construction addr sr30-' � 7 UTI-1-
' n0
Flood G District
8. Date of subdivision Approval plain zone Zone 0/3
9. Private dwelling 0 Estimated Cost c4'')Pu DO NOT WRITE IN THIS SPACE
"
I/O �,p Type of room No.
10. Multi family 0 /"OO. � 84413 Der
11. Commercial ❑ _ Kitchen
12. Other �r
7.5'1 6-eDining Rm.
13. No. of stories ( - c-1 d ` 1 LP Living Rm.
C / 5•
- a9,L Bed Rm.
14. Foundation — Full 0 Half 0 Crawl 0 Slab ❑ Bath [
15. Materials — Wood, Cement 0 Other 0 Deck
16. Type of heat — Oil 0 Gas 0 Electric 0 Other el Closed porch
Family Rm.
17. Garage — 1 ❑ 2 ❑ ' Sun room
18. Swimming pool - Size Garage
19. Storage shed — Size 105412-f_A..Q/11 ttfAn Shed/0 5(,X
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 12- No. of feet side / b No. of feet rear 12- 1
23. Distance from nearest building: Front Ft. side Ft. side Rear
A/ i � .
24. Distance back from line or st eet Ire Fr. rear lot line .30 Side line
25. H.I.C.R. No. (0937 / J/
LOT RELEASED BY Signature t •! / 02 �^
PLANNING BOARD Address /0 Seems �0E� eJ
Date S= /dills
PL .
. FOR LOT n"
Indicate location cf garage or accessory building -
Additicns with dashed lines
• Sewerage disposal (cesspool) e
. Weil D
-- I 12IGN'r or- INS I
I (lot ftrear)
kbuttor's I _ Abuttor's
game - - Name
Lot ft ' �Q Lot #
REAR YARD �` �
:f this is a If this is
orner lot, ft. corner lc
grite in name 1 write in
�f steet. I name of
I
t. other
G 0
o -0 k u street.-
€— (8)' _ 6
J
•
V .1� y
SIDE YARD S DE YAS
HOUSE
G FT. 0 0 til - - - ISO •
4/n )
Q W
I
SET BACK
ft. •
o 1 c
I
( c e frontage)
,
f2-i9s
• (NAME OF STREET)
\ /
- BUILDING DEPARTMENT
• CONSTRUCTION SUPERVISOR FORM
LEASE PRINT: • . . r 1 '. •
.. . /�' /1�'n�• ,�.{,� .44/) .
/��L
JOB LOCATION: • ice ?_S cx Iso 1 ► 0IJV V 1 \ • oz6erm `
• - NUMBER STREET . _VILZ.AGEE� ` I
OWNER OF PROPERTY: ' KISS'.
UJ� -yt/�
CONSTRUCTION SUPERVISOR: •
�� a ` `� 1 .�l��J `7 SCI( J
.• -� /� VANE t.�G� ( �. y�. LICENSE NO. PHONE NO.
ADDRESS: - '1 D S cth 11"' E"-'�'" ' t K_() . • s • 061 15 .
LICENSED DESIGNEE:
(IF OTHER-THAN SUPERVISOR) NAME LICENSE N0. .
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
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 DEMOLITION INVOLVING THE STRUCTURAL ELEMENTS OF BUILDING
AND STRUCTURES ONLY PURSUANT TO THE STATE BUILDING CODE AND ALL OTHER APPLICABLE LAWS OF THE
COMMONWEALTH, 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 IMMEDIATELY NOTIFY THE BUILDING OFFICIAL 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 3E SUBJECT
TO REVOCATION OR SUSPENSION OF LICENSE BY THE BOARD.
2.16. ALL BUILDING PERMIT 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 DEMOLITION 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 IMMEDIATELY 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 :ICENSING CCI
STRUCTION SUPERVISORS IN ACCORDANCE ::ITH SECTION 109.1.1 OF THE STATE BUILDING CODE. I UNDERST;2
THE CONSTRUCTION INSPECTION PROCEDURES AND THE SPECIFIC INSPECTION AS CALLED FOR BY THE BUILDING
OFFICIAL. . •
INSURANCE COVERAGE: •
I have alceur t I' lity soura❑nce policy or its substantial equivalent which meets the requirements of M3Uth.152
If you hay ..ecked vis. p:ease incictte the type coverage by checking the aco ccriate box. .
7
A liability insurance pc:icg .
Other type of :.idemnity 0 Bond
OWN n'S IN RANCE WAIVER: I am aware hat th rcensee does ret have the insurance covert^,e requirec =y
C `ao er1 the Mass. G erg L-ws. ant ..at my acp
azure cn this permit : :icaticn waives this requirerrer.t
�40 yi Check one:
OwnerC2 • AgeK
Sgn . or Ohne(et O..ner s Agent �`ff��
TU E• ' '
�:. . `— - COMMONWEALTH OF MASSACHUSETTS
� _r=••.
DEPARTMENT T OF INDUSTRIAL ACCIDENTS
:• - 600 WASHINGTON STREET
James.1 Corinne!: BOSTON, MASSACHUSETTS 02111 •
turn::ssione•
WORKERS' COMPENSATION INSURANCE AFFIDAVIT •
1, fill GS • r .lam la I'tQ_ 1 Wits _ _S14 tat a
(licensee/pennincc)
• with a principal place of business/residence at: •
120 , ' •1-- . ' ,c -n i''' Ii :c.) , O - fw •
(City/State/Zip)
do hereby certify, under the pains and penalties of perjury, that: -
r..a.
Fam an employer providing the following workers' compensation coverage for my employees working on this
job.
• `(-r/
�A C.73_%ci 6_ ,C44.
Insurance Company Policy Number
[ J I am a sole proprietor and have no one working for me.
I J I am a sole proprietor, general contractor or homeowner (circle one) and have hired the ccn:actors listed below
who have the following workers' compensation insurance policies:
Name of ContractorInsurance Company/Policy Number
Name of Contractor Insurance Company/Policy Numb::
Name of Contractor Insurance Company/Policy Numb::
o I am a homeowner performing all the work myself.
•
NOTE;.Please be aware that while homeowners who err-ploy persons to Co maintenance.construction or repair work on a
dweiiin; of not more than three units in which the homeowner also resides or on the grounds appurtenant thereto are dot centrally
considered to be employers under the Worker' Compensation Act(GL C. 152.sect. 1(5)). application by a homeowner for a license
or permit may evidence the leeal status of an employer under the Workers' Compensation Act
1 andsn:and that : cnpv of this statement will k forwarded to the Department of Industrial Acdden n.Office o:ins::r.^.c for coverage
vcriri:s::on and that ' . ' -
:acture to Lure cpve.�e as reclaim::under S:_pn 25.E o: 'tiiGi 152 can lead to arra i:apov:ca of criminal penalties
ccnsts:n[of: fine of ute to 51500.00 and/or impri:onrt_nt of up to one yea:and dvii penalties is the form of a S:__ Work Order and 2
fine of 5100.00 : d:v a£airs:re.
�y da: of a5 , 19 93
i; A/ it
• Suggested Affidavit for Home Improvement Contractor Permit Application
For Office
No Use Only �I�AIi'IE OF(:I�I�'/�5WI�I •
Permit No. CII
�V
Date
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
MGL a 14:A requires that the"reconstruction.alteration.renovation.repair.modernization.conversion.in provemeni,removal.demolition.
or construction of an addition to any preexisting owner-occuoied 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 captions,along with other
requirements.
Type of Work: d�7 l 3J17JC tC 1 Est. Cost
Address of Work R' o / 33 Web+ L4A1 OU l ( 1
Owner Name: .1M1AL It _y at \'a_ .no a ( .I
Date of Permit Application: • •
•
I hereby certify that:
Registration is not required for the following reason(s):
_Work excluded by law
ob 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
c 142A:
Signed under penalties of perjury:
I hereby apply for a permit as the agent of the owner:
7g937v
Date r or.:Ai acd0 lop
Notwithstanding
Registration No.
OR:
Notwithstanding the above notice, I hereby apply for a permit as the owner of the above property:
Date Owner Name
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