HomeMy WebLinkAboutBLD-93-701 _ - 6/09.1 4o,9a 6119 3
r ,:- : TOWN OF YARMOUTH oKFe' &lrin
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• MATTACIIE 5� �J
"�,+ .a..nor$'f7% Application for a Permit to Build No. 70
UPON FINAL APPROVAL Ik -Ir I MAP /6 LOT I r.
FEE MUST ACCOMPANY THIS APPLICATION. DATE 23 rt +1 19 cl3
The undersigned hereby applies for a permit to build 'W/x/9.3
according to the following specific ions 0 noR044411
1. Name of property owner \11,\J._,\ t 1 o 91/44194. 45-67 41( nit.
Address 2 ! u tat -Vitt-- ��- -L.•.c* ►h A ,
2.Name of Architect(if any) Tel.
3. Name of builder c c t //A b` -/.. .S ss ddress s W_. • 0' a 1,1• '
4. License No. n 60 -5 Tel. -775 '-232 -
1
5. Name of Mason Address
6. License No. Tel. rr
7. Construction address S- 7 tJR,\ k S .- CisW Mvct-b .
8. Date of subdivision Approval plain zone 8 4 A`i - JO Zoneict Q 7,5—
9. Private dwelling 0 aed Cost diUr. DO NOT WRITE IN THIS SPACE
• — Say-9,, NQe/L f 7 Type of room No.
10. Multi family 0 ----
11. Commercial ❑ . Kitchen
12. Other 0 %P �Y 2-21 ! Datgee-r-AS " Dining Rm.
13. No. of stories .a`r�rw�� �' a � Living Rm.
Bed Rm.
14. Foundation — Full 0 Half 0 Crawl 0 Slab 0 i 7tAey ath
15. Materials — Wood 0 Cement 0 Other 0 p-e= act 0-0 ` neck
16. Type of heat — Oil 0 Gas 0 Electric 0 Other 0 PRE q s17 7o •o-t Closed porch
c clI '
17. Garage — 1 0 2 0 _ y Rm.
• 5e +�i%Sun un room
18. Swimming pool - Size ' �j 70 'mv Garage
19. Storage shed — Size yep;•.6 ` �`/ z_cy,do "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
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. ti9?- IRS a�Gt�.-� ��
LOT RELEASED BY Signature n
PLANNING BOARD Address c i1 i r4�' - YtP tif
Date kat , L.,— /1/14-D /ex y' -
sr
I BUILDING PERMIT APPLICATION SIGN OFF
,
APPLICANT: k/ 1111141-/A. IKO Ce-oq\J BUILDING PERMIT II:
ADDRESS: I ' u Q.,k -"v�-ti,__^.I TELE. NO.: DATE FILED:
BLDG. SITE LOCATION: 374-54k!AALS. "Q. MAI,p1 /D 1uTf/t / rt
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 REQUIREMENTR (U) IIIR'1'tRlt:AI.' DIRTRIt:'PU (U) noon
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-
EPTAGE
FIRE DEPARTMENT: DETERMINESNTFOSCOMPLIANCEPTOAL STATE ANDANDFR TOWNRLIC REQUIREMEN`I'ASHEALTHFFORIPERSONAL
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 DEPART MEt -. DATE: 5-....247.... 54;) 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
1LL STUMPS AND/OR BRUSH MUST BE DISPOSED OF AT AN APPROVED SITE. A SIGNED RECEIPT FROM THE
)ISPOSAL SITE MUST BE SUBMITTED TO THE BUILDING DEPARTMENT PRIOR TO ISSUANCE OF THE BUILDING
ERMIT. ,,LL,, �
OMMENTS:Bacc >,�/5'T>7f/WQ3E/P3 etas,, riper
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. PLOT PLAN
FOR LOT #
. Indicate location of garage or accessory building
Additions with dashed lines
Sewerage disposal (cesspool)
Well 0
I I
I (lot ft. rear) I .
Cr 1
buttor's I Abuttor's
ame IName
of # I Lot #
REAR YARD
this is a • If this is
orner lot, (AQ('. . corner lot,
rite in name 1 � write in
f street. 1 . ® name of
3•. • _-,i - -�/ a other
ii• •
.tU 1'i�ttk. ,o street. .
b • . I s
4 I
SIDEmYARD 1 SIDE YARD
o UV" FT. 0HOUSE L __Iie- _ FTo .
• Q .
• I .
SET BACK
..•.U.i..ft.sq
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0
(lot In ft. frontage)
\ / kSta fs Q. -
\ /
\ / / (NAME
E OF STREET)
`
/ ` Information
AOVE1 tAte.-4.is
/ \ I Plied by
\
:LARK NORTH POINT
•
Suggested Affidavit for Home Improvement Contractor Permit Application
For omee Use Only NAME OF CITY/TOWN •
Permit No. •
Date
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
MGLe 142A requires that the"reconstruction.alteration,renovation.repair,modernization.conversion.inprovement.removal.demolition.
or construction of an addition to any pre-existing owner-occupied budding containing at least one but not more thamfour duelling units....or
to structures which are adjacent to such residence or kidding"be done by registered contractors,with certain acept ions,along with other
requirements.
Type of Work: R 1 I c Est. Cost
Address of Work 6 d 3 W A'+U I t % ' Q . •
Owner Name:
Date of Permit Application: 2 3 114`.) k eicr •
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 permit as the agent of the owner:
Date • Contractor Name Registration No.
OR: •
Notwithstanding the above notice, I hereby ap Iv for mit as the owner of-the above property:
fru 1w
Date Owner N me
A'� COMMONWEALTH OF MASSACHUSETTS
• DEPARTMENT OFINDUSTRIALACCIDENTS - •
•
600 WASHINGTON STREET •
James) Campoeu BOSTON, MASSACHUSETTS 02111 •
Comnss one r
) •
WORKERS' COMPENSATION INSURANCE AFFIDAVIT •
At) ti U lN2—b
(l ice nsee/permittee)
• with a principal place of business/residence ac
Jp (City/Sate/Zip) ilk 4
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
[ ) 1 am a sole proprietor and have no one working for me. -
[ ) I am a sole proprietor, general contractor . omeowne, (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
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 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 statement will be forwarded to the Department of Industrial Acddenu' Office of Insurance for coverage
verification and that failure to zeeure coverage as required under Section 25A'of MGL 152 can lead to the imposition of criminal penalties
consisane of a rine 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 S100.00 it:tmt'
r f ( , 19 r-
Liee^seciPer^a-__ Licensor/Permit.,,
BUILDING DEPARTMENT
. . CONSTRUCTION SUPERVISOR FORM -
: .' PLEASE PRINT: .".'
./LJ
' f ,: 1 n
JOB LOCATION: fl.p2' . . S-et/•?/''L .. IJ C} 1 1 \ t �`t- 10 - �'I
. . • NUMBER ` 4 , ' STREET VILLAG .
OWNER OF PROPERTY: ' W'1 '!l6/n-r,7 �o 2 `�•y/ •
CONSTRUCTION SUPERVISOR: - • '
. NAME . LICENSE
,�N7O. .PHONE N0. . .
•
. • ADDRESS 1 1' 'VI R 1 A-i i • ••�ie .. .PU447/111.;v7 yal • /v( /"7— -0/1“/
•• LICENSED DESIGNEE: Y kGvt' •\ '\ . • trk.C.4 S • )617' ��/
(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
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, RE?AIR, 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 BE SUBJECT
• TO RE:'OCATION 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 L`EMEDIATELY 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 CC
STRUCTION 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 curren liability insurance pclicy cr its substantial equivalent which meets the requirements cf MGLth.152
Yes .. No O
If you have checked v_s, please incicte the ty;e c average by checking the ap:r:;nate bcx. - • _ •
A liability insurance pc:icy 0 Cher type of :.idemndy 0 •
OWNER'S NSUAANCF WAIVER: I am aware that the ccensee do^i re! `ay. the insurance coverage requirec tv
Chazter1.2 f the !. • . Inc L•ws, ane that my svan.:ture cn :a: per= ::;:ic:::cn waives this requirement./� C`ecx cr.e:
:41 to"— f/ice -= CNner Agent C
S.anrure m ....net c:Q r
r' .+
SIGNATURE: elLDING OFFICIAL APPROVAL:
TOWN OF YAMOUTIi
BUILDING DEPARTMENT
HOMEOWNER LICENSE EXEMPTION ,
PLEASE PRINT:
DATE
041
LOCATIONl ^s--;z ��
JOBhl LL yl e. W it/9,2)4-014\
NUMBER STREET ADDRESS SEfTION OF,TOWN
"HOMEOWNER" W�\1 1 � r ` C ?-{511/41
NAME HOME ONE WORK PHONE
PRESENT MAILING ADRESS 21 Rq(1-AA-+t, 2V�
CITY 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 WHO DOES NOT POSSESS A LICENSE, PROVIDED THAT THE 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/SHE 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 THAN ONE HOME IN A TWO-YEAR PERIOD SHALL NOT BE
CONSIDERED A HOMEOWNER. SUCH "HOMEOWNER" SHALL SUBMIT TO THE BUILDING OFFICIAL,
ON A FORM ACCEPTABLE TO THE BUILDING OFFICIAL, THAT HE/SHE SHALL BE RESPONSIBLE
FOR ALL SUCH WORK PERFORMED UNDER THE BUILDING PERMIT. (SECTION 109.1.1)
THE UNDERSIGNED "HOMEOWNER" ASSUMES RESPONSIBILITY FOR COMPLIANCE WITH THE STATE
BUILDING CODE AND OTHER APPLICABLE CODES, BY-LAWS, RULES AND REGULATIONS.
THE UNDERSIGNED "HOMEOWNER" CERTIFIES THAT HE/SHE UNDERSTANDS THE TOWN OF YARMOUTH
BUILDING DEPARTMENT MINIMUM INSPECTION PROCEDURES AND REQUIREMENTS AND THAT HE/SHE
WILL COMPLY WITH SAID PROCEDURES AND REQ REMENTS. }�
HOMEOWNER'S SIGNATURE �> //!
APPROVAL OF BUILDING OFFICIAL • / - e l
NOTE: THREE FAMILY DWELLINGS 35,000 CUBIC FEET, OR LARGER, WIL :E REQUIRED
TO COMPLY WITH STATE BUILDING CODE SECTION 127.0, CONSTRUCTION C. 'OL.
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes No ❑
If you have checkedyes, please indicate the type coverage by checking the appropriate box.
A liability Insurance policy ik Other type of indemnity ❑ Bond 0
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by
Chapter 142 of the Mass. General Laws, a that y signat ; on . permit application waives this requirement.
C ck one:
(AA llr _19Der.�"'.*'( / Owr•,e Agent O
. $rgnature of Owner or Perrier s agerrC _ _ ___ •-- -