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V oneccs .; Application for a Permit to Build No. 70 q
UPON FINAL APPROVAL q_„o MAP 97ieZ
FEE MUST ACCOMPANY THIS APPLICATION. DATE 4:113-
19 9 3
The undersigned hereby applies for a permit to build g/��99
ccording to the following specifications %/2o/yg
1. Name of property owner ce ..1)y Tel.
Address Ole
- f,, ...A f1,, rfla I
2.Name ofArchitect(ifany) �iC�4-2}1 A,e JS P - mo 9632. Tel. 2753 4
a Name of builder T&.,/b cf 12. 1--c1^4P.•rso,n Address S9 ,(2. ftr+3 Q.-0
4. License No. '' Tel. 3e/et- 07 ZS
5. Name of Mason Address
6. License No. Tel.
7. Construction address • Pehn tc A X S.yc.es b. eL Its . a, cc y
FloodODistrict gay
8. Date of subdivision Approv I plain zone Zone
s�l
9. Private dwelling 0 Estimated�Coo st ket0f• DO NOT WRI E IN THIS SPACE
10. Multi family 0 VV1 /LAC /Oad _ / Type of room No.
19-3 EN. grin. 5 of I
11. Commercia7( a 1/4gicar�yn, ��� Sitehe1rLgvnp. /
8smr 7I -sf
12. Other ❑ / mUit7 /
//��' is ' < q
nes
13. Na of stories Arx- /ill ii til.-,n;
Be m�7aiZ A
14. Foundation — Full 0 Half 0 Crawl Slab 0 g5e Bath /
15. Materials — Wood 0 Cement 0 Other 0 16 7r , Deck
16. Type of heat — Oil 0 Gas 0 Electric 0 Other 0 f a`&a Closed porch
17. Garage — 1 0 2 ❑ 8 6. 9r Family Rm.
Sun room
18. Swimming pool - Size Garage
19. Storage shed - Size ' , - c. . ' Shed
•20. Stove - Wood ❑ Coal 0 t ' Alterations
21. Size of lot: No. of feet front No. of feet rear Na of feet deep
22. Size of building. No. of feet front ' Na of feet side Na of feet rear _.
23.Distance from nearest building: Front Ft. side Ft. side Rear
/4. Distance back from line or street Fro - .r lot line Al Side line
25. H.I.C.R. No. /oetc, r �; 4)rd` ��LOT RELEASED BY ! Signature � / _
PLANNING BOARD Address S - • /eHk4 's ili
Date / c/r O.s,-c //c, a ? CC7
r73/93 y
C',/ , BUILDING PERMIT APPLICATION SIGN OFF
APPLICANT: ! - - • ' =•.- BUILDING PERMIT #:
'/ADDRESS: •
TELE. NO. : " ^%" DATE FILED:
•
DG. SITE LOCATION: C? MAP//: LOT#:
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 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: �1 ,_� n DATE: N/A:
4. HEALTH DEPARTMEN w - - - DATE: e k3/ 3 N/A:
INDUSSTRIAL AND/OR COMMERCIAL PERMITS
5. WIRING INSPECTOR: DATE: N/A:
6. PLUMBING INSPECTOR: DATE: N/A:
7. FIRE DEPARTMENT: DATE: N/A:
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:
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BLM/89
3193Q3 A
. ., • • -.• • TOWN OF Y'. ., .. —
ARMOUTH . .
k • BUILDING DEPARTMENT . :
. CONSTRUCTION SUPERVISOR FORM
•' PLEASE PRINT: ., ..
10B LOCATION: .277.:-..0. 710WW 3 ICdr ' �y etc o yt<</ --- . .
NUMBER • • STREET VILLAGE -.
'.L4WNER OF PROPERTY: • 6.4111 6 S,f'h1.. L .• f/'
�CONSTRUCTIONtrSUPERVISORr•- - •OJGvs ! p1. '�j&,4,o".,- • 059 L'IZ • 3reer,tic
NAMELICENSE NO. .PHONE NO.
e iler
• 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
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
CO:LMONWEALTH, 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 IhQIEDIATELY 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 IMMEDIATELY CEASE UNTIL A SUCCESSOR LICENSE HOLDER IS SUBSTITUTED
ON THE RECORDS OF THE BUILDING DEPARTMENT. .1 ' ' • • ' - ' ' 7 ' ' .
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 UNDERSTF:
THE CONSTRUCTION INSPECTION PROCEDURES AND THE SPECIFIC INSPECTION AS CALLED FOR BY THE BUILDIN,
OFFICIAL. .. . .. ... .. .
INSURANCE COVERAGE: • - '
I have a currentliabdity insurance peticy or its substantial equivalent which meets the requirements of MGLth.152
Yes ❑ . . .. No 0
' If you have checked v`s. please indicate the type a average by checking the ap:re:riate bex. - • '..t . .
. '
A liability insurance pciic/ 0 C:her type of :.idemnity 0 • Bond ❑
OWNER'S INSURANCE WAIVER:! am aware that the licensee tees ret `nve the insurance ccverge require::y
Chapter 152 of the Mass. General Laws. ana that my signature on this permit ::;:ica::cn waives this requirerren:
Checx cr,e:
Cwner= Ager: 0
,S.:na,wa at .-..ner et tl.ner s agent _e'
w
. ' '
SIGNATURE: v 6 /� BUILDING OFFICIAL APPROVAL: 1.
COMMONWEALTH OF MASSACHUSETTS
fl = E
- P DEPARTMENT OF INDUSTRIAL ACCIDENTS
600 WASHINGTON STREET
•
James,: CampbellBOSTON, MASSACHUSETTS 02111
comm,ss oner WORKERS' COMPENSATION INSURANCE AFFIDAVIT •
•
1, Dc 4 ( P. McMAec e'--
(l icensee/permittee)
• with a principal place of business/residence an
[/ { q- A1. O!nnt C �crwei.l�t� �e. otter
(City/Bute/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
am a sole proprietor and have no one working for me.
•
[ ) I am a sole proprietor, genera] 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 Contractor Insurance Company/Policy Number .- . . • -•
Name of Contractor Insurance Company/Policy Number . -
Q 1 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 statui 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 SI500.00 and/or imprisonment of up to one year and civil penalties in the form of a Stop Work Order and a
Mine of S100.00 a day agunst me. n
V Signed thin //7�iil'i�`�/""'�^-day of 7/p , 19 93
Lice s- rI* :^ Lice.^.sor/Permit:3r
5770/
• 1
• Suggested Affidavit for Home Improvement Contractor Permit Application
For Office Use Only NAME OF CITY/TOWN
Permit No
1)ete
• AFFIDAVIT
• Home Improvement Contractor Law
Supplement to Permit Application
MGL a 142A requires that the"reconstruction.alteration.renovation.rt-eair.modernization.conversion.inprovement.removal.demolition
• orconsttvaion of an addition to:Inv pre-mating nvmer*xcunted budding containing at bast one hut not more than fourdwelling unrts....or
to structures witch are adtacent to such residence or budding"be done by registered contractors,with certain exceptions.along with other
requirements-
Type
equirementsType of Work: /'/Anch/ e' r 1../K ,stile//,(4179 tEst. CostL5a16
//ddress of Work Sel AAQ06,14•A1W /�6. c-N` lit• a7-CCce
(/Owner Name: C.en t d Sec y
ate of Permit Application: t/Z7/9N
1 hercby certify that:
•
Registration is not required for the following reason(s):
_Work excluded by law
_Job under 51.0(7(1
_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 IMPROVE.MENT WORK DO NOT HAVE
ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL •
c. 142A.
Signed under penalties of perjury:
t.,ereby apply for a permitminas the agent of the owner. •
747/13 (lam utif gneferser.
easagene
Date •NNamc Registration No. •
OR: ,��� / 00-6 l
• Notwithstanding the a,eve notice, I hercb apply for a permit as the owner of the above property:
•
Date Owner Name
• RESIDEST1AL BUILDINGS ENERGY INFORMATION
(LOW RISE) (�
'E,;.:,1'`• A .. BUILDING LOCATION 1 �R�A. � Mgeli `le( . .
_
>✓,s.94- II_-. - G' 4_ �_ ---..)- u-mow1._ _ cnt,e_t U yA s PiCoR4
Creoo *It II Aow cno I� LID, Isr� sstoq I �e w wrPe�r> `�
5*(l.tr
1 kbw II AD I ZI___ Il LID I tog I w UOD . C .DUD1} (ADS UDS)
AA Hoo
4 i �; M (AD> I LDS I c x �j( Y _ __�_
-rte I ADD I to P L1e 1 ,ote I _
Imo; w..24-1,- . H&J 1 . II uIJ I I\
pr c.... OP khr;x:..1S Dco4s . (per- A..;)
r?mow,
( Z'/ \( I1 )
= .o5 x100 =. r to
cup1
IIF WINDOW AND DOOR AREA EXCEED FIFTEEN (15) PERCENT OF THE GROSS WALL ,
AREA THE OVERALL WALL Uo VALUE MAY NOT EXCEED0._167 (Uo = 0.105 FOR ELECTRIC
RESISTANCE HEAT)
ROOF/C l:NG,FLOOR OR FOUNDATION U-VALU .2, L=_E.REQUI�EME.NTS Or:ABLErDO9.1
1%FIND Uow FOR WALLS
WALL Uoa• _ (Aw 1.1w) i (A: Ucl s (Act Uool
Aou.
(.3;1, Z, 16 ! ,W
u =61ro - -WL1 --( it/ X , oq' 1 + ( I.._ Xild_-1 _ ,07qt. • '
01 /n
1 I 1_p74-5"--- I i r�vi-
kr
.
krICtr-7 1eS 'D�5 I LoS 10.7 tea.\ - / .S
i Ler uck
X0r.,
J' 'Kitt 'II LCI ' ll LIK , '
c5 ,. I�r • III
A,,,„ 1
5 00 ✓ .7 I /A., I II I ''UIIS r
07
or
["..64::41.11
<w.: I' .1 II LoW, II .001 I
.. .. . .. A . .
•
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ALTERNATE COMPLIANCE: SECTION 2009.3
THIS STATED Uo (or U) VALUES OF ANY ONE ASSEMBLY, SUCH AS ROOF/CEILING, WALL, OR
FLOOR, MAY BE INCREASED AND TIIE to (or U) VALUE FOR OTHER COMPONENTS DECREASED,
PROVIDED THAT TIIE OVERALL HEAT GAIN OR LOSS FOR TIIE ENTIRE BUILDING ENVELOPE
IDOES NOT EXCEED TIIE TOTAL RESULTING FROM CONFORMANCE TO TIIE STATED Uo (or U)
VALUES. . .
ENVELOPE ALLOWABLE Uo (PER TABLE 2009.1)
(Aw •0.0S) + (Ac '0.65) + (Aoo 040) + (AoR 0.033) + (AoF 0.0 (Aowp 0.051 c Auow,.ets.
0.40)+(
.
Au.owAB E Pea TADS 2009.1
'ELECTRIC RESISTANCE HEAT U-VALUE WALLS = 0.05, U-VALUE WINDOWS = 0.40
•
ENVELOPE ACTUAL Uo (USING ACTUAL VALUES OF DESIGN OF ENVELOPE)
(Aw Uw1 + (Ac Uc1 + (Aon Uool + (AOR UOR) + (Me UoF) 1 (AOw. Liowr' _ A r/. & i
— �� r:r,;.'
r x 1 ✓ x_14./ x )� x \ar/ ti t/ x 4 —
ACTUAL UAL
COMPARE VA?UES
THE •- VALUES FOR ENVELOPE ACiU.AL MUST BE LESS THAN OR EQUAL TO . VALUE
OF ENVELOPE ALLOWABLE TO PASS. n
PASS f I FAIL
•
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ceipt....„ . .
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I THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH 1W 1nop
a�� TOWN of YARMOUTH
No riot
- flinpnstt nstriutinn f rrmit
Permission is hereby granted & CI ses-cpXY
to Construct g ( a idual $ewag sp�sal System
at No ���� 1 •:1-._� sy-lJ-__ // _ r/ 2 sq,as shown on the ap ication for Disposal Works Construction • Street` . D f -i
DATE415
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