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Home My WebLink AboutBLD-93-704 „of•Yqti cis( tI poi ri ” 4,o. TOWN OF YARMOUTH oAnr:,. y! o K1 Few 9/17193 'f• MATTA HC 5 // ,mo o* g; Application for a Permit to Build No. X70 7 UPON FINAL APPROVAL & i � ' 7rMAP 79 LOT /!',/ FEE MUST ACCOMPANY THIS APPLICATION. DATE 9/17 19 93 The undersigned hereby applies for a permit to build 7//,/93 ac/COrding to the following specifications vf. Name ofpropertrtyy.00wner Samuel Saike Tel(617)648-2353 Address 52 GolFers Circle , So. Yarmouth 2.Name ofArchitect(ifany) Tel. '4:Name of builder Stephen G . Eldridge _AddressReer 1374 Rte 134 , E. Dennis 4. License No. 007435 Tel. 365-3939 5. Name of Mason Address �6. License No. Tel. ✓7. Constructionaddress 52 GolFers Circle , So. Yarmouth Flood District 8. Date of subdivision Approval plain zone C. Zone R 9. Private dwelling Er-. Estimated Cost DO NOT WRITE IN THIS SPACE Type of room No. 10. Multi family 0 V e 1600.00 h �g•wt.t �y'�D / 11. Commercial 0 -#i%y eA-' /� ' t _ e e Kitche�f_ 12. Other ❑ .�-• v� " -`" Dining Rm. 13. No. of stories I 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 O. 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 2a Distance from nearest building: Front Ft. side Ft. side Rear 24. Distance back from line or street From rear lot line Side line A5. H.I.C.R. No. 108315 LOT RELEASED BY 'Signature ).9171-n, -h. (fzei- t/ p PLANNING BOARD Lddress Rear 1374 Rten. 0. Box 736 Date East Dennis , Ma . 02641 • TOWN OF YARMOUTH - . BUILDING DEPARTMENT • . / CONSTRUCTION SUPERVISOR FORM • ' • PLEASE PRINT: JOB LOCATION: 52 Golfers Circle Sn YYrmnrirk : • NUMBER . STREET . . VILLAGE - OWNER OF PROPERTY: ' Samuel Boike • • ` CONSTRUCTION SUPERVISOR: . Stephen G. Eldridge - 007436 3Rq--IRRq • NA LICENSE NO. PHONE NO. • . ADDRESS: Rear 1374 Rte' 134-P. 0. Box 736 ' East Dennis , Ma 02641 ' . ' LICENSED DESIGNEE: . • (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 t 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, 1 ALTERATION, REPAIR, REMOVAL OR DEMOLITION INVOLVING THE STRUCTURAL ELEMENTS OF BUILDING a 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- c CONTRACTOR OR CONTRACTOR TO THE PERMIT HOLDER. i• 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 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 I.'2IEDIATELY CEASE UNTIL A SUCCESSOR LICENSE HOLDER IS SUBSTITUTED • ON THE RECORDS OF THE BUILDING DEPART:ENT. ' . . ' . ' " . ' I HAVE READ AND UNDERSTAND MY RESPONSIBILITIES UNDER THE RULES AND REGULATIONS ,FOR _ICENSING CC:I- STRUCTION SUPERVISORS IN ACCORDANCE WITH SECTION 109.1.1 OF THE STATE BUILDI\G CODE. I UNDERSTAN: THE CONSTRUCTION INSPECTION PROCEDURES AND THE SPECIFIC INSPECTION AS CALLED FOR BY THE BUILDING OFFICIAL. . INSURANCE COVERAGE: ;ry I have a curre liability insurance pcticy or is substantial equivatent which mees the requirements of MGLth.152 ' - ,Yes 0 - No 0 If you have checked v`s, please indicate the type c average by checking the arrcprtate bex A liiabdity insurance pc:icy ❑ C:her type of :.idemnity❑ Bond 0 - --'- - OWNER'S INSURANCE WAIVER:I am aware that the t:censee dcei ret have the insurance coverge required =r Chapter 152 of the Mass: General L'ws, and that my signature on tr:s permit ::;Iic:tion waives this requiremer.;. • - - • Check ore: • Owner° Agent 0 Signature at Cwner et Owners Agent • f SIGNATURE: I • ,A,^ A Piet,) "A7 BUILDING OFFICIAL APPROVAL: • r Suggested Affidavit for Home Improvement Contractor Permit Application - - - - • Y For Office Use Only.--- - `,—:--- NAME OF CITY/TOWN -Permit No. South Yarmouth Date AFFIDAVIT Home Improvement Contractor Law • • . Supplement to Permit Application MGLc 142A requires that the"reconstn,ction,alteration.renovation.repair.modernization.conversion,inprovement,removal,demolition. or construction of an addition to any preexisting owner.occunied building containing at least one hut not more than fourdwellino 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: Roofing - - Est; Cost $1600.00- --- Address of Work 52 Golfers Circle Owner Name: Samuel Boike • Date of Permit Application: 9/17/93 I hereby certify that: - Registration is not required for the following reason(s): Work excluded by law _Job under SI,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: q/i7/9 3 Abri, j. Date Contractor Nam Registration oNo. • OR: • Notwithstanding the above notice, I hereby apply for a permit as the owner of the above property: Date Owner Name 'sem —` COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF INDUSTRIAL ACCIDENTS • \ZS 600 WASHINGTON STREET • James,: Campoeu BOSTON, MASSACHUSETTS 02111 • Comm:ssroner WORKERS' COMPENSATION INSURANCE AFFIDAVIT • • • I Stephen G . Eldridge (licensee/permittee) • with a principal place of business/residence an Rear 1374 Rte 134, East Dennis, Ma . r17R41 (City/State/Zip) do hereby certify, under the pains and penalties of perjury,that: N) I am an employer providing the following workers' compensation coverage for my employees working on this job. Liberty Mutual WCI-312-457589-011 Insurance Company Policy 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 Contractor Insurance Company/Policy Number . . Name of Contactor - 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,sea. 1(5)),application by a homeowner for a license or permit may evidence the legal suras 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 overage verification and that failure to secure 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. Signed this 17th day of September , 19 93 LicenaeeiPvmir.re: /� ^-- LiaasotiPermiro: