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Home My WebLink AboutBLD-93-718 4 . r j TOWN OF YARMOUTH �� p1a/ t 0(A it c •';• 14 MAT04Rato S ' Application for a Permit to Build No. AWS UPON FINAL APPROVAL ( 93 MAP 3 LOT 7- /7 FEE MUST ACCOMPANY THIS APPLICATION. DATE tr.:d / 19 The undersigned hereby applies for a permit to buildN� I._ 9��i ac�rding to the following specifications yKP AName of property owner //n/n1CONNFN/GIfinN Tel.3 9768 Address /0 64/1-122A-, CA'A-C- t4 9 2.Name of Architect(if any) \ - (� Tel. 3. Name of builder a _ " . Oa ilit.:41•ddress )20 Senrivcstt (2 Lv• 4. License No. G'SI 3S Tel. 76o-4'c ° 5. Name of Mason Address 6. License No. '--- ,Tell -- 7. Construction address /0 0 LPc,eit—e.) a'-e- Flood District y0 8. Date of subdivision Approval plain zone (/ - Zone 9. Private dwelling 0 Estimated Cost , DO NOW WRITE IN THIS SPACE 10. Multi family 0 /000• "— r gyf Z Type of room No. 11. Commercial 01 Vilrb ' Kitchen 12. Other ❑ Dining Rm. 13. No. of stories cQ, Ca-- 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 0 2 ❑ Family Rm. Sun room 18. Swimming pool - Size Garage 19. Storage shed — Size 8)C )0• Shed $'X,Z' 2a 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 ( 2 No. of feet side 8 No. of feet rear (2- 23. 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. /093794-,ai'. r.�o LOT RELEASED BY Signature "`l idlr?dA L et-+uee in, PLANNING BOARD Address /e99 jcr;.a-aaG. Date r, trA 4.4_0-ua' I `eA-•Od4(,II- 179r' COMMONWEALTH OF MASSACHUSETTS p, t zu,L' DEPARTMENT OF LNDUSTRIAL ACCIDENTS • . 600 WASHINGTON STREET • James GamDDeL BOSTON, MASSACHUSETTS 02111 • • -oma:ss orae, WORKERS' COMPENSATION INSURANCE AFFIDAVIT • • efig— age /J.firea eedvac:fr-s,. (licensee/perm i tree) • with a principal place of business/residence at. - . 120 6?wr/6 / 0 � idrl//S , (Ciry/Sate/Zip) do hereby certify, under the pains and penalties of perjury,that: jm an employer providing the following workers' compensation coverage for my employees working on this job. arNi4 C 23 t cre C • 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 Contractor 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,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 Insurance for coverage verification and that failure to secure coverage as required under Section 25A'of MGL 152 can lead to tiie 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. D Sign �C/ 741 day of / i , 19 / 3 - 4 L, ..se..iPermi^eo- LiccnsodPetmirtor PLOT PLAN • FOR LOT 1; • Indicate location of garage or accessory building Additions with dashed lines • Sewerage disposal (cesspool) e • Wpll Ei • I (lot ft. rear) Abuttor's Abu' Name • ,S.,-*'rc a ,.. I Nam Lot # - 0 ( O rt 11�• Lot n REAR YARD , 7f this is a • .--- /0' If t corner lot, 1 ft. 0X 12.-- /nid_. corn write in name • wri of street. I name I 17, snit'. G othe c • -p• / v stye Ts 'b • • , • • SIDE YARD • SIDE YARD • HOUSE /7 • FT. r) 0 FTO 0 • • t • • • SET BACK • • • ft I • (loth ft. frontage) .. \ / P/M✓E 4vE \ / \ / (NAME OF STREET) \ / / / \\ -Information / \ Supplied by ,e..,1_,,, Suggested Affidavit for Home Improvement Contractor Permit Application • For Office Use only—_ . . — NAME OF CITY/I.OWN. r ` Permit No. Date • AFFIDAVIT Home Improvement Contractor Law , Supplement to Permit Application MOLc.142A requires that the"reconstruction,alteration.renovation.repair.modernization.conversion.inprovement,removal.demolition. orconstnuction of an addition to anv pre-existing owner-occupied building containing at least one but not more than four dwelling units....or to structures which are adjacent to such residence or budding"be done by registered contractors,with certain exceptions,along with other requirements. ,, . ... Type of Work: _ . - - iniS 'u e St 60--',- Est: Cost "Pon-- _ Address of Work /00 f/y7ua ' !z' S• (VT% PAOo Owner Name: long kb (Omni 40g- N r r ' Date of Permit Application: - V7.-0 - I hereby certify that: . • Registration is not required for the following reason(s): • ork 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 here y app y for a permit he agent o the owner: 929 3 I ' ' Gl ave• /6937V Dat Contractor Name Registration No. OR: ' • Notwithstanding the above notice, I hereby apply for a permit as the owner of the above property: ' i ...a • • I , -'• ' Date M•••` s 'J>dr /owner Name / TOWN OF YARMOUTH BUILDING DEPARTMENT HOMEOWNER LICENSE EXEMPTION PLEASE PRINT: DATE JOB LOCATION / EGC L/G e S D. V144,11,-/-242., NUMBER STREET ADDRESS SEC OF TOWN "HOMEOWNER v/u/ L s • .1 .1.... 1 • taa.. .L 2 3 NAME HOME PHO WORK PHONE PRESENT MAILING ADDRESS Saiirg____ CITY OR TOWN 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 ATTACHED 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 WILL COMPLY WITH SAID PROCEDURES AND REQUIREMENTS. HOMEOWNER'S SIGNATUREIA F1,iad//I-.' Ariel/el/ex/lir vri APPROVAL OF BUILDING OFFICIAL INSURANCE COVERAGE: I have a Ycurrent es ❑ liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. NoIf you have checkedtes, please indicate the type coverage by checking the appropriate box A liability Insurance policy Other type of Indemnity 0 Bond 0 OWNER'S INSURANCE 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. d e/,J5 cp `CI}eckone: cure of 01 2Qp.�/ Owner 1 Agent 0 ignature o1 er or Owner s Agent /