BLD-93-710 t ,O •Y.:3
iLt ?to TOWN OF YARMOUTH mKF
91.3/93
MATTAC�EES
eto ,,,.W Application for a Permit to Build No. rI/° •
UPON FINAL APPROVAL I` _ 1-0.1-0 - AP /7 • LOT ,/7`
FEE MUSTACCOMPANY THIS APPLICATION. \DATE 001993
-" " 11The undersigned hereby applies for a permit to build 9/ 793
according to the following specifications /20/93
1. Name of property owner \W JA tO e. HlvoC Tel.$t-fllf
NAddress )2VILLAA A2, roA73Uru1
2.Name ofArchitect(if any) Tel.
Na Name of builder HDmf DWNt'2, Address
4. License No. Tel.
5. Name of Mason Address
6. License No. Tel.
7. Construction address 31 HNRSTrSI , /e m
fl Flood �' District
8. Date of subdivision Approval plain zone C. Zone R''i-C
9. Private dwellingLlyr. DO NOT WRITE IN THIS SPACE
Estimated Cost (fro_93 /0� /Zee- Cr2C, Type of room No.
10. Multi family 0 enzooetee, / �/ Afuts I
,�
11. Commercial 0 / V ,207-A 7pgy3 Kitdhen
12. Other 0 UFDI" To Co c/`"`zj 14 Co Dining Rm.
� n o Living Rm.
13. No. of stones � ef 0, 0 Rm.
14. Foundation— Full 2/Half 0 Crawl 0 Slab 0 �f Bath
15. Materials — Wood 0 Cement 0 Other 0 Deck
7,16.Type of heat — Oil 0 Gas 0 Electric 0 Other 0 Nr Closed porch
;7-17._Garage — 1 0 2 ❑ - • "` FFamily
Rm.
ro
m
18. Swimming pool - Size I .• 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
' c 2 Size of building. No. of feet front No. of feet side J No. of feet rear
Z23. Distance from nearest building: Front Ft. side Ft. side Rear
. 3124 Distance back from line or street From rear lot line Side line
`25: H.I.C.R. No.
LOT RELEASED BY \Signature ���"'�' Ii c ,
1 PLANN•I•NG BOARD Address I2 V/LLA . c •
Date '
.0rz v
9//b /93 &Ix,
n4 y . -_TOWN\OF YAMOUTII .
- - - --BUILDING DEPARTMENT
.
sL 1I011E0WNERLICENSE EXEMPTION
PLEASE PRINT:
\DATE 7/pI9.3 ��JJ
\ JOB LOCATION ,J) 41)1,95 fn !/j,Q. Wego--4,0th,-tf
NUMBER STREET ADDRESS SE ION OF,TOWN
\"HOMEOWNER" /5 ey, 1 p et /age 593 -.in 1.) SYY--403‘
NAME HOME PHONE WORK PHONE . .
\PRESENT MAILING ADRESS /Z j/41,4 az,
F�eorzu - 11I� 0201
3
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/SIZE 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 FAR."i STRUCTURES.
A PERSON WIIO CONSTRUCTS MORE THAN ONE HOME IN A TWO-YEAR PERIOD SHALL NOT BE
CONSIDERED A HOMEOWNER. SUCH "HOMEOWNER" SHALL SUBMIT TO TILE BUILDING OFFICIAL,
ON A FORM ACCEPTABLE TO THE BUILDING OFFICIAL, THAT HE/SITE SHALL BE RESPONSIBLE
FOR ALL SUCH WORK PERFORMED UNDER THE BUILDING PERMIT. (SECTION 109.1.1)
THE UNDERSIGNED "HOMEOWNER" ASSUMES RESPONSIBILITY FOR COMPLIANCE WITH TUE STATE
BUILDING CODE AND OTHER APPLICABLE CODES, BY-LAWS, RULES AND REGULATIONS.
TUE UNDERSIGNED "HOMEOWNER" CERTIFIES THAT HE/SHE UNDERSTANDS TIIL TOWN OF YARMOUTH
BUILDING DEPARTMENT MINIMUM INSPECTION PROCEDURES AND•REQUIREMENTS AND THAT HE/SHE '
WILL COMPLY WITH SAID PROCED S ND RE. IREMENTS.
\HOIMOW NER'S SIGNATURE L try "Cl, ,4
APPROVAL OF BUILDING OFFICIAL
NOTE: THREE FAMILY DWELLINGS 35,000 CUBIC FEET, OR LARGER, WILL BE REQUIRED
TO COMPLY WITH STATE BUILDING CODE SECTION 127.0, CONSTRUCTION CONTROL.
INSURANCE COVERAGE:
have a current liability incur rice pclicy or its substantial equivalent which meets the requirements of MOL Ch. 142.
\ Yes ❑ No ❑
If you have checked vess, please indicate the type coverage by checking the appropriate box.
A liability Insurance pclicy 0 Other type cf indemnity 0 Bond ❑
OWNER'S INSURA;' E WAI ER: I am aware that the licensee dces nct have the insurance c: •=•age requitedb
by
Chapte 1 the/lass. G✓ era'. Laws, and that my signature cn this permt application w.
ivesthis requirement.
i;emcrt.
�i 1 � Che < cre:
Owner Agent ❑
• 1yru....a or C'nter c Onter s ..r
"\
•
Suggested Affidavit for Home Improvement Contractor Permit Application
For Office Use Only NAME OF CITY/TOWN
Penult No.
Date
AFFIDAVIT
Home Improvement Contractor Law
• Supplement to Permit Application
MGL e..142A requires that the"reconstruction.alteration.renovation.repair,modernization.conversion.inprovement,removal.demolition.
or construction of an addition to anv preexisting owner-occupied building containing at least one hut not more than fourdaelling 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: fret J'/442444" %t/r Est. Cost a0
\ Address of Work /24/4 rrp,r_ 9 orP
Owner Name: /072,414,72 7? #9' S-
\ Date of Permit Application: srpe /p /My
\I hereby certify that:
Registration is not required for the following reason(s): •
_Work excluded by law
Job under 51,000
_Byitding 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. I42A.
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 n I he by ap• '. for a permit as the owner of the above property:
lir 1
\ Date wrier it/m
•
is - -- -
=_- — COMMONWEALTH OF MASSACHUSETTS
a = t
el.P `='r DEPARTMENT OF INDUSTRIAL ACCIDENTS
f 600 WASHINGTON STREET •
James J Gamooee BOSTON, MASSACHUSETTS 02111
commsstoner WORKERS' COMPENSATION INSURANCE AFFIDAVIT •
I, 421/g/-0flewP
(licensee/perminee)
• with a principal place of business/residence at /
\ /Z KLig ,�/iz., / �/7o /11/7Gro7s
(City/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.
•
Insurance Company _ Policy Number -
[) I am a sole proprietor and have no one working for me.
[ am a sole proprietor,general contractor orC, omeowner irde one)and have hired the contractors listed below . ..
7w o 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 -
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 a copy of this statement will be forwarded to the Department of Industrial Accidents'Office of lnsuranri for coverage
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 S 100.00 a day against mc. i
q
\ Signedthi D A day of ,S'i�. -ii291� , 19 93
`.Licensee/Pe... :net Licensor;Permi :or,