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;` �MATTAC�E 5� �� �
C.a.„),6 Application for a Permit to Build No. 71� -
s UPON FINAL APPROVAL Uj q� /1-3MAP / LOT 4, 9'
FEE MUST ACCOMPANY THIS APPLICATION. DATE . _ M.n 19g3
The undersigned hereby applies for a permit to build y�za/99
according to the following specifications .
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�Nameofproperty owner JOSCP>M Bieck} IER1 Tel.37? 349/
Address 36. Jc-gl, tmiJ
2.Name of Architect(if any) Tel.
3. Name of builder .071-A 2 Address
4. License No. Tel.
5. Name of Mason Address
a License No. Tel. '
instruction address?' JcFMNSDV LA, W' yAR1yc 1174
/ Flood / District 0
8. Date of subdivision Approval plain zone Zone Ds /v
9. Private dwelling 0 Estimated Cost . DO NOT W ITE IN THIS SPACE
10. Multi family 0 900- 00 S X / ul
Type of room No.
11. Commercial ❑ Kitchen
12.Other C1� 2' F.A//a' 120. C-0— Dining Rm.
13. No.of stories Living Rm.
Bed Rm.
14. Foundation — Full 0 Half 0 Crawl 0 Slab ❑ 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 2r5(/Z' /
20. Stove — Wood 0 Coal ❑ Alterations
21. Size of lot: No. of feet front No. of feet rear - No. of feet deep
I
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
25. H.LC.R. NO.°
LOT RELEASED BY Signature ------/ frJ > ,14 ,A$n4
PLANNING BOARD Address
Date .1
/
`Mo" TOWN OF YARMOUTH
BUILDING DEPARTMENT
HOMEOWNER LICENSE EXEMPTION
/1 PLEASE PRINT:
IDATE t 9 J ✓ 9� -
j JOB LOCATION 31 1\-)"N ?Dr LA-
Rw ARMo
NUMBER STREET ADDRESS SEC ION OF TOWN
"HOMEOWNER" 'JI) )] IP ICC 11 ggrqa 9T 7
9/
NAME HOME PHONE WORK PHONE
PRESENT MAILING ADDRESS 3e._ k F-)4 ���� -,A -
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u) • yal2Ntd M� �� SS- 026 )1
COR MOWN STATE ZIP CODE
THE CURRENT EXEMPTION FOR "HOMEOWNER" WAS EXTENDED TO INCLUDE OWNER—
OCCUPIED DWELLINGS OF ONE OR TWO UNITS AND TO ALLOW SUCH HOMEOWNERS TO
ENGAGE AN INDIVIDUAL FOR HIRE WHO DOES NOT POSSESS A LICENSE, PROVIDED
THAT SUCH HOMEOWNER SHALL ACT AS SUPERVISOR. (STATE BUILDING CODE SEC-
109.1.1)
DEFINITION OF HOMEOWNER:
PERSON(S) WHO OWNS A PARCEL OF LAND ON WHICH HE/SHE RESIDES OR INTENDS TO
RESIDE, ON WHICH THERE IS, OR IS INTENDED TO BE, A ONE OR TWO FAMILY
ATTACHE D OR DETACHED STRUCTURES ASSESSORY 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 REGU—
LATIONS.
THE UNDERSIGNED "HOMEOWNER" CERTIFIES THAT HE/SHE UNDERSTANDS THE TOWN OF
YARMOUTH BUILDING DEPARTMENT MINIMUM INSPECTION PROCEDURES AND REQUIRE—
MENTS AND THAT HE/SHE WILLL COMPLY WITHJ�ROCEDURES AND REQUIREMENTS.
'; HOMEOWNER'S SIGNATURE8.ts,”1-Ae
'_ APPROVAL OF BUILDING OFFICIAL
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INSURANCE COVERAGE:
1 have a curt liability Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes No ❑
If you have hecked Its, please Indicate the type coverage by checking the appropriate box.
A liability Insurance policy Other type of Indemnity 0 Bond 0
OWNER'S INSURANGE.WAIVER: I am aware that the licensee does not have the insurance coverage required by
Chapter 142 of the Mass�General Laws, and that my signature on this permit application waives this requirement.
C eck one:
�ACITi v1x Owner Agent 0
Signatu of e or Owner's Agent •
PLOT PLAN .
•r
FOR LOT O •
• Indicate location of garage or accessory building
Additions with dashed lines
Sewerage disposal (cesspool) e .
. Well 10
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•. I i I
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(lot J l3 ' ft. rear)
Abuttor's I Abu
Name
I 30' Nam
Lot n
Lot „
I1V
REAR YARD rt� t
If this is a
corner lot, 1 ft. • corn
write in name • I '/ wri
of street. t - e nam
;; I C e, ..othe
•Q o ;✓ o sire
v •
V
It,
SIDE YARD SIDE YARD
• HOUSE
•
FT. 0 0 FT/-)
4 I •
• v,` • I D°
O
SET BACK
•
o I ft.
I `.
I
(lot 1 0 O �• 0 ft. frontage) •
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\ / Z K/72\//1/0b/ A);)
\ /
\ / (NAME OF STREET) /,, `7p
\ • • 3� 1C-�1�`�`�"d 7(1
/ Informa`?on\ �f4 _
/ \ Supplied by VC/! "1
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` 74z: COMMONWEALTH OF MASSACHUSETTS
p,
• . DEPARTMENT OFLNDUSTRIALACCIDENTS
• • 600 WASHINGTON STREET •
James J Camooeu BOSTON, MASSACHUSETTS 02111 . •
Con,m:ironer WORKERS' COMPENSATION INSURANCE AFFIDAVIT
•
1, Te5/1 '/—/ Ri&,// /if j4 I
(licensee/permittee)
• with a principal place
e oo1f(business/residence an/
Z
rty
(City/ to/Zip)
do hereby certify, under the pains and penalties of perjury, that:
•
(j I 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.
j I am a sole proprietor, general contractor o • (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 -
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 homeowoer for a license
or permit may evidence the legal sums 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 secure coverage as required under Section 2SA'of MGL 152 can lead to the imposition of criminal penalties
consisdng of a fine of up to $1500.00 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 mc.
Signed this day of , 19 9.
• I .L.LLasttl
LicenseciP/:.i :e:- Licensor/Permir:or
• '^ Suggested Affidavit for Home Improvement Contractor Permit Application
For Omee use Only"'_ -_ - =r - - NAME OF CITY/I'O WN - '
Permit 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 toanvpreexisting owner-occupied buildingcontaining;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 Work: erAttiZ t1'..3 -- Est.-Cost rent &'r
Address of Work 30Z A*?VA/r-v/ o/ / •
Owner Name: /s ieev-//t
Date of Permit Application: 7/,,6/
/
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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 hereby apply fora_pe it as the owner of the above property:
�oAtag-1
Dal Owner Name