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Home My WebLink AboutBLD-93-702 Y :p1;•Yqit ,k4,... , neo TOWN OF YARMOUTH O ` I y N ""Tej : .55 4' Application for a Permit to Build No. 7Ga �'' �% c3i UPON FINAL APPROVAL qc.1(0 MAP 71 �LL,,O,/T�� /� FEE MUST ACCOMPANY THIS APPLICATION. DATE ' 19 47-3 The undersigned hereby applies for a permit to build 2 according to the following specifications ,/1 /9_3 � Name ofproperty owner -Pt 4-1.1 N°^41-4- Tel. 09esse7 Address 3J9 tJ Man) ST ,..Co. /,.2mi.tit H 2.Name of Architect(if any) Tel. 3. Name of builder MAJA/irF Address 4. License No. Tel. 5. Name of Mason Address 6. License No. Tel. L-7. Construction address 3J N.47n,.J 1T So, Vie rtoci't14 8. Date of subdivision Approval plain zone (i Zone ct yo 9. Private dwelling 0 Estimated Cost DO NOT WRITE IN THIS SPACE 10. Multi family 0 �� jizis� 77Fir Type of room No.�/ 11. Commercial 0 7-02//7— a y/� *At— 9/Z2q�� Kitchen 12. Other X /7�O a zz /g Dining Rm. 13. No. of stories � y 4 35oO Living Rm. 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. 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. . 4 LOT RELEASED BY Signature ' `""'"` PLANNING BOARD Address 31-, N• M.4 .0 Sr Date So • /0e,•444.10-a Suggested Affidavit for Home Improvement Contractor Permit Application . • For Often Use Only NAME OF CITY/TOWN Permit No. Dine AFFIDAVIT Home Improvement Contractor Law . Supplement to Permit Application MGL c.142A requires that the"reconstruction.altemt ion.renovation.renair,modernization.conversion.inprovement,removal.demolition. orconstruction of an addition to any pre-existing owneroccuoied 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 exceptions,along with other requirements. Type of Wor� ��iy/° T,.t/Ts -Est. Cost Address of Work Owner Name: • 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. Signed 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 heply for permit s the owner of the above property: - / �— ale Owner Name i 7- COMMONWEALTH OF MASSACHUSETTS P' • . ..,,....- ,.=,.. DEPARTMENT OF INDUSTRIAL ACCIDENTS ,: 600 WASHINGTON STREET James J Camopeu BOSTON, MASSACHUSETTS 02111 • • Comm:sstoner WORKERS' COMPENSATION INSURANCE AFFIDAVIT ✓ ?4tt. tt0•rtc ' I, (licensee/permittee) • with a principal place of business/residence an�1�/ c—S? 7 �- ytfo,✓ cs% So. Yi,zwlO N /t'1r4 Od.GGV, (City/Sure/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. Insurance Company Policy Number I am a sole proprietor and have no one working for me. ( ] I am a sole proprietor, general contractor4i•• _ • circle one)and have hired the contractors listed below • . who have the following workers' compensation . policies: --. • • _ -• • Name of Contractor . Insurance Company/Policy Number . . ...... . Name of Contractor Insurance Company/Policy Number �Naame of Contractor Insurance Company/Policy Number I am a homeowner performing all the work myself. g • 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(CL C. 152,sect. 1(5)),application by a homeowner fora license or permit may evidence the legal status of an 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 Insurance for coverage verification and that failure to iecure coverage as required under Section 25A'of MGL 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 S100.00 a day against me. q Signed this /6 day of /T/�T— , 19 / LicerseeiPerrnin::. LicernsoriPermirrtr PLOT PLAN '� • • 1 I • • FOR LOT it • Indicate location of garage or accessory building Additions with dashed lines Sewerage disposal (cesspool) . Well • I (lot ft. rear) Abuttor's I Abul Name I Nam- Lot I • Lot # REAR YARD • If thisisa Ift corner lot, ft. - corn write in name • writ of street. • I - name • � a ..othe 7 ,d o sire d 'U • SIDE YAR' • SIDE YARD • HOUSE I . F i .. ) . • FTI) . • • 774.1.-77-2 r----r--- ' . • Cr I • \ SET BACK • • ft a, o I • (lot ft. frontage) .. • \ / 3P77 //97w Si^ • \ / N / (NAME OF STREET) / \ -Information �/ fr itC.......\ / \ Supplied by