HomeMy WebLinkAboutBLD-93-714 ee( cd MC/73
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I V', � o TOWN OF YARMOUTH
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MTTACHL 5
5s):Itoo.AnolV, " Application for a Permit to Build No. 7/1/
UPON FINAL APPROVALild 9 - --19 /MAP 10 Z LOT ais-
FEE MUST ACCOMPANY THIS APPLICATION. DATE -9— /7 19 93
The undersigned hereby applies for a permit to build %/x/93
according to the following specifications 74-p/fra
1. Name of property owner /YVr./I 4 -rV �cf 4 cr d/'7 Tel. 362-s/2.1-
Address s-o 6;ro_hn.A) AA/ X47e2Oncicnr.+2ir
2.Name of Architect(if any) Tel.
reZt3. Name of builder dirt sTr9 I-1- , . _ti /6 yd—AI AA 'ddress r,,-rvrr4r/
2>14V lile73z S
4. License No. o4./of A Tel. d/2--r-91'ic9
5. Name of Mason Address - -
6. License No. -- Tel.
7. Construction address %sr C evezevt hi �� -lnvrr 714-7
Flood District 1) !JO
8. Date of subdivision Approval plain zone e— Zone Il 7
9. Private dwelling 0 Estimated Cost DO N WRITE IN THIS SPACE
Typst of room No.
10. Multi family 0 aoo ip4
sr
.
1
11. Commercial 0 rR / 5lNM •I °C441- O ` Kitche
12. Other fzum ovrnoaf Dining Rm.
13. No. of stories a14i„eeLiving Rm.
Bed Rm.
14. Foundation — Full 0 Half 0 Crawl 0 Slab 0 �c' v, Bath
15. Materials — Wood 0 Cement 0 Other 0 Deck
16.Type of heat— Oil 0 Gas 0 Electric 0 Other ❑ 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. /oo>y° /
LOT RELEASED BY Signature AP-- - .-, -44-741.--e-r.,-
PLANNING BOARD Address io 41s" /167-1,771-9,2t).4,
Date Co7rdr" .t04
Suggested Affidavit for Home Improvement Contractor Permit Application .
•
• For Office Use Only• NAME OF CITY/TO WN
Permit No. X.47 ,11,92,7777417—
Oak
,11,927QDelo
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
MGLc.142A requires that the"reconstruction,alteration.renovation.renair,modernization,conversion,inprovement,removal.demolition,
or construction of an addition toanv pre-existing ownertxcunied huildinQcontaining 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: . .-. r
Est: Cost -"I/006 __-_-- _
Address of Work iCtr/ c u /N
Owner Name: (eau
Date of Permit Application: - yr'— 2 0 — 9 3 .
I hereby certify that:
Registration is not required for the following reason(s): •
_Work excluded by law
_Job under S1,000
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/hereeby apply for a permit as the agent of the owner:
he
Date 7�1-5 � ��Z� Name �iL /oapse0
Contractor Name / Registration No.
OR: •
Notwithstanding the above notice, I hereby apply for a permit as the owner of the above property:
Date Owner Name
COMMO? EALTH OF MASSACHUSETTS
DEPARTMENT OF RN'DUSTRLALACCIDENTS
600 WASHINGTON STREET
nines: Car::e!: BOSTON, MASSACHU EITS 02111
Cor.•in:ss:era WOR ERS' COMPENSATION LNSURANCE AFFIDAVIT
•
I, / 2 a
Oieensedpe. ' et)
With a principal place of business/residence ac
(City/State.rZip)
do hereby certify, under the pains and penalties of perjury, that:
[] I am an employer providing the following workers' compen adoo coverage for my employees working on this
job.
////������// un `
47srA4 /� // �r � l...�'/.7 hztr / 000 2230/ 7V
Insurance Company Number
[j I an: a sole proprietor and have no one working for me.
[j I art. a sole proprietor, general contractor or homeowner (thole one) and have hired the contractors listed c::::,
who have the following workers' compensation insurance poiid_.
•
Name of Contractor Insrance Company/Poliry Number
Name of Contractor : Insurance Company/Poliry Number
Name of Contractor Irsnranc Company/Policy Number,
[i I am a homeowner performing all the work myself.
Nen: Please be aware that while homeow:en who employ persons to co =tintessa nes,construction or repair ro rk on
wriing of riot more that three units it which to homeowner also resides o:e:the grounds apou.-tmaac thereto are not gae::_Y •�^-'
considered to beemployers under the War:cn'eompc:t:tioe Act(CL.C.152.sac- 1(5)).application by a home':for
or perri:may evidence the legal status of an employer under the Workers'Cc t cts:don Act..
I u.._.n.z.. that a cagy of this statement will be forty,.,;.:to the Dcp m .::f :du...:.1 Ac c':cd Osage of insurr. for cot..;.
yeC..c;t cn that.allure to secure =nap as recuired under Section 251..:MC!.152 cm lead to the i.reposition of-..._. .�__
ersiscr= aline ofuoto $1500.00m..�'orir.prsons.. r '4Or : . ' •
=' -:of u: to one gel:and cr".t penalties in the form o. a Stop CCer;c Order s;:a
En:of S'.:::0.0 a day:pins:mire. •
19 2 3
�
day of �/i
of
License_"_:.;,it :: License:/P J
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