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HomeMy WebLinkAboutBLD-93-694 caoYgk " m41-4-4 9113 [53 itt...“' o TOWN OF YARMOUTH © (C fro q/13/0 ` MATTAC HE �J LI C t// Application for a Permit to Build No. �n9T UPON FINAL APPROVAL 'NZ-I"f MAP /A / LOT C ac 7 FEE MUST ACCOMPANY THIS APPLICATION. , DATE 9//3 9 ' 3 The undersigned hereby applies for a permit to build //� 93 according to the following specifications 9 f#9-2 1. Name of property owner edm4 F;N�aJ �riN;gA-A) Tel. Address 9 r'�'%A,.zs0 - an.,o vr'T' 2.Name ofArchitect(if any) Tel. 3. Name of builder �1o•t9k 2,�Pat.,,,ri-e- Address 'Vi Co.- '1- Pc4i f,/ V r. J /)qo — fav2 4. License No. Cls^j c�� s Tel. 5. Name of Mason Address 6. License No. Tel. ,.7. Construction address 9 Cc )1 Myytd Flood District , 8. Date of subdivision Approval - plain zone Zone 9. Private dwelling 0 Estimated Cost ''(A /D' ?DONOT WRITE IN THIS SPACE • 10. Multi family 0 /syp q_i3�� Reis, � < Type ofroom No. 11. Commercial 0 Kitchen 12. Other Er 9 .0 olf .ki /74,) CCN f) g Dinin Rm. 13. No. of stories Jo r ,,a D _ ring Rm. Bed Rm. 14. Foundation — Full 0 Half ❑ Crawl 0 Slab ❑ Sa2-p Bath I 15. Materials — Wood 0 Cement 0 Other 0 /0 / 00 DeckWt o z' 16. Type of heat — Oil 0 Gas 0 Electric 0 Other 0 ) Closed porch 17. Garage — 1 ❑ 2 ❑ Ace-e-- 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 2a 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. /ObQal (fr LOT RELEASED BY -.,----Signature /1/ "A. s PLANNING BOARD ,-----Addresacv Co o1 e,r 62� Date Kr', 04 Plass 0 APPLICANT: `dk, q P:, , o BUILDING PERMIT t: ADDRESS: /CI (1,..n o (-\.) TELE. NO. : DATE FILED: BLDG. SITE LOCATION: (/ IN/i q_Npfl ( J4) MANI: /0.7 / LOTll: C 2O 7 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 TUE RESPECTIVE ORDER, PRIOR TO BUILDING INSPECTOR ISSUING TUE 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: V-- )03-9-3 N/A: •iUST AND/OR COMMERCIAL PERMITS S. WIRING INSPECTOR: DATE: N/A: G. PLUMBING INSPECTOR: DATE: N/A: 7. FIRE DEPARTMENT: DATE: N/A: • b' N/S iT ime y ( Pen -- 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 1 . RUCTIING UPERVISOR - CONSTRUCTION SUPERVISOR FOR2f • •' :PLEASE PRINT: - , r (f *1.• .•'JOB LOCATION: q 4WNW;, W A Li • tG�^a 41/412 .244— • NUMBER Gm d. STREET - VILLAGE - • ` A. OWNER OF PROPERTY: CC/AdA V',N, cG..,. • • ' CONSTRUCTION SUPERVISOR: `1.O-4C 1, ✓) ct✓.•e..:ac� • C7)5M-16 S— ' �90='12y2 NA,� - LICENSE NO. .PROSE NO. .t ADDRESS: 'S Li Co r--C t ,471- T� • • . LICENSED DESIGNEE: - ; (IF OTHER THAN SUPERVISOR). NAM LICENSE NO. . 2.15 RESPONSIBILITY OF EACH LICENSE HOLDER: 2.15.1 THE LICENSE HOLDER SHALL BE FULLY AND COMPLEIELY 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 TEE CONSTRUCTION. RECONSTRUCTION, ALTERATION, REPAIR, RE!CVAL OR DE•!OL2TION INVOLVING THE STRUCTURAL EL=ANTS OF BUILDING AND STRUCTURES ONLY.PURSUANT TO THE STATE BUILDING CODE AND ALL OTHER APPLICABLE LAWS OF THE COMMONWEALTH.EEALTH. E'.E:: 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 LICE::SE HOLDER SIALL IMMEDIATELY NOT:FY THE BUILDING OFFIC2AL IN WRITING OF THE DISCOVERY OF ANY VIOL'.T:O::S WHICH ARE COVERED BY THE BUILDING PERMIT. \ • ' 2.15.4 ANY LICD::SE= WHO S1L1LL WILLFULLY• VIOLATE SUBSECTIONS 2.15.1. 2.15.2 OR 2.15.3 OR ANY ' OTHER SECTION OF THESE RULIS ANC REGULATIONS AND ANY PROCEDURES. AS AYE:DED, SHALL 3E SUBJECT TO REVOCATION OR SUSPENSION OF LICENSE BY THE BOARD. • 2.16. ALL BUILDI::G PERMIT APPLICATIONS SHALL CONTAIN THE NAME. SIGNATURE AND LICENSEE NUMBER OF THE CONSTRUCTION SUPERVISOR WHO ES TO SUPERVISE THOSE PERSONS ENGAGED IN CONSTRUCTION, RECON- STRUCTION, ALTERATION. REPAIR. R%!OVAL OF DD!OLITION AS REGULATED BY SECTION 109.1.1. OF THE CODE AND THESE RULES AND REGULATIONS. IN THE EVENT THAT SUCH LICENSEE IS NO LONGER SUPERVISIN SAID PERSONS, THE WORK SHALL Ir.EDDIATELY CEASE UNTIL A SUCCESSOR LIC.^_:SE HOLDER IS SUBSTITUTED ON THE RECORDS OF THE BUILDING DEPARTMENT. I HAVE READ AND T.:DERS_;::D NY RESPONSIBILITIES UNDER THE RULES AND REGULATIONS FOR LICENSING c: STRUCTION SUPERVISORS I:: ACCORDANCE ::Ii.. SECTION 109.1.1 OF ma STATE BUILDING CODE. I UNDERST: THE CONSTRUCTION INSPECTION PROCEDURES AND THE SPECIFIC INSPECTION AS CALLED FOR BY THE BUII.DIS OFFICIAL. • • INStj:.ANCz C:VERACH ' I hate a CTIe... jacn.ty :nvnnce ;-::e;or as st: :cntiJ er:Natent vouch metre:..e reet:re:.ents of IASL t152 Yes _. No Q It you have ehecxS_. zi-_:e ine:::e tate y,.e c^rerage by checking the ::::."ate b x. . A Iia:ttity insurance pc:e; Err C:her type at :leemnrty 0 e:: 0 C'NNC,'C :NS:.-...:Cz wAr.'EEA::am aware ..._: :he i:cartter !- -• _ _ Cb.:::::r c . .15D . ..._ •ta.-- ..itne - ::-Ns. :he ..._. -y ._._ :hi: tern _:: _.:.. nt a: __ .c. :ec _.ie_ - - 1.:.::::•...:a c: ....,.r :. -....4.1:-::r: C.sre:_ .__.. ... C ' SIGNATURE: .../.7LOta, BUILDING OFFICIAL APPROVAL: Suggested Affidavit for Home Improvement Contractor Permit Application For orrice Use only NAME OF CITY/TOWN Permit No. Date • AFFIDAVIT • Home Improvement Contractor Law - Supplement to Permit Application MGLc 142A requires that the"reconstruction,alteration.renovation.repair,modernization.conversion,inprovement,removal.demolition. or construction of an addition to any precristing owner-occupied budding 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 exceptions,along with other requirements. • Type of Work: /A o�� v(le)mo/5 /./7C/ Est- Cost 1s3/0 Address of Work V W//it/VO W f)y 7-l? —Owner Name: ...10Svc, 4 Date of Permit Application: I hereby certify that: Registration is not required for the following reason(s): _Work excluded by law _Job 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. Siened under penalties of perjury: I hereby apply for a per ' as the agent of t ,• owner: eS 3 Jet. /C727 .2 2_ Date • .ntractor Name Registration No. OR: • Notwithstanding the above notice, I hereby apply for a permit as the owner of the above property: Date Owner Name Hz -- COMMONWEALTH OF MASSACHUSETTS - - �'�� R DEPARTMENT OF LNDUSTRIAL ACCIDENTS C . WASHINGTON STREET aures J Camopee BOSTON, MASSACHUSETTS 02111 - Comm:ssrone WORKERS' COMPENSATION INSURANCE AFFIDAVIT • N. 1 Ante; �r w iQi+---„"#* (licensee/permitree) - - — • with a principal place of business/residence at ('3 cy r'oc_k (Ciry/State/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. surance Company jPolicy Number I am a sole 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: -- " -- • . -- - ._ -.- - -- - . - -- - - - -- Name of ContractorInsurance 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 homeowner: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 Aa(CL C. 152.sect. 1(5)), application by a homeowner for a license or permit may evidence the legal status of a.n 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 coverage 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 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 S 100.00 a day against me. 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