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Home My WebLink AboutBLD-93-719 R icy( 7/2 3 $ ' TOWN OF YARMOUTH Y 1-3 H f H II • t I. TC,,;:::10 s :- Applicptlon for;a Permit to Build No.1719 UPON FINAL APPROVAL q'a' I MAP / Z . LOT 4-V- 17 . . , i FEE MUST ACCOMPANY THIS APPLICATION. i DATE ` VW 19 93 The undersigned hereby applies for a permit co-build • t _ ;` . 7/a 0.3according to the following specifications' , , Name of property owner & au\.- ( T rveS Tel. — Address 41 ' YbeiiC..-t w i/I/, 2.Name of Architect(if any) cj Tel. c--3. Name of builder c_NtkriveS /4S Address 3 rL?ct wrneP i 4. License No. O y79 t9 Tel. 790-5D1-715--- 5. Name of Mason Address 6. License No. Tel. L7. Construction address 91 &,.{c e-r_. w Floo District yAs- 8. Date of subdivision Approval plain zone / Zone J 9. Private dwelling 0 Estimated Cost DO NOT WRITE IN THIS SPACE �8� 10. Multi family 0 Type of room No.ry/ 11. Commercial 0 .7 1 �z�f � � fL� /— Kittcchhen I 12. Other 1/5 1 o Dining Rm. 13. No. of stories c— �_ 0, Living Rm. Bed Rm. 14. Foundation — Full 0 Half 0 Crawl 0 Slab 0 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 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 Fro rear lot li : Side line 25. H.I.C.R. No. 1/1 6$J1 l LOT RELEASED BY A— Signature /'S� /� ��7 PLANNING BOARD 1 c3[Addres !�[gnee- %1 Date f ._. 0/74r01crel 'Vil ar 6120 3 TOWN OF YARMOUTH - BUILDING DEPARTMENT • • CONSTRUCTION SUPERVISOR FORM ' PLEASE PRINT: ' • 7,/ � ' JOB LOCATION: 7 VIcarrtiny /al 10. 1�V12cv° . NUMBER . . 1 STREET • . . tLAGE ' OWNER OF PROPERTY: - -Um .j `(eoS (tom ". E C/fes CONSTRUCTION SUPERVISOR: . isrC tSr tct s • LICENSE L.J-1 / I•C ! 703 TV ADDRESS: c • U. • �'A, LICENSED DESIGNEE: . 0 ZI 1S. ` O • • . . (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 • COMMONWEALTH, 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 IMEDIATELY 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 3E 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 DEPARZENT. ' ' ' • . . .. ' ' ' . • I HAVE READ AND UNDERSTAND MY RESPONSIBILITIES UNDER THE RULES AND REGULATIONS ,FOR :ICENSING CC:1- STRUCTION SUPERVISORS IN ACCORDANCE WITH SECTION 109.1.1 OF THE STATE BUILDING CODE. I UNDERSTA.N: THE CONSTRUCTION INSPECTION PROCEDURES AND THE SPECIFIC INSPECTION AS CALLED FOR BY THE BUILDING OFFICIAL. . INSURANCE COVERAGE: 1 have a current liab lit' insurance pclicy or i:s substantial equivalent which meets the requirements of MGLth.152 Yes ❑ r No ❑ :. If you have checked v_s• please indicte the type coverage by checking the ap:rcpriate bcx ,�".'. • S, . A liability insurance pc:icy 0 Other type of :idemnity 0 - Bond 0 •• • --- - . OWNER'S INSURANCE WAIVER:I am aware that the licensee acset have the insurance coverge re. uirea f Chapter 152 of the Mass: General Laws. ana ma: my signature on t',:s permit :ep:ica:len waives this requirerner.:. . • • Check one: • Owner) Agent 0 S,gnature m One cr O.ne t • SIGNATURE: id, • BUILDING OFFICIAL APPROVAL: • =`� COMMONWEALTH OF MASSACHUSETTS • DEPARTMENT OF INDUSTRIAL ACCIDENTS • • 600 WASHINGTON STREET • James CampbellBOSTON, MASSACHUSETTS 02111 • • Cpmm:sstoner WORKERS' COMPENSATION INSURANCE AFFIDAVIT • I, c2...xme-., \cs, (licensee/permittee) • with a principal place of business/residence ar. (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 Na 1 am a sole proprietor and have no one working for me. ( ) I am a sok proprietor, general contractor or homeowner (circle one) and have hired the contractors listed below • who have the following workerscompensation insurance policies: •... Name of Contractor Insurance Company/Policy Number . . Name of Contractor • Insurance Company/Policy Number Name of Contractor Insurance Company/Policy Number 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 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 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 5100.00 a day against me. Signed this l day of , 19 Lice:see/Per .,:net ' P Lice::sor/Permiror • • Suggested Affidavit for Home Improvement Contractor Permit Application For Office Use Only - - - NAME OF CITY/I'OWN Permit Na Date AFFIDAVIT • Home Improvement Contractor Law . Supplement to Permit Application MGL c.142A requires that the"reconct ruction,alteration,renovation,renair.modernization,conversion,inprovement,removal,demolition. or construction Man addition to any preexisting owner-occupied building containing at least one but not more thagfour 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. C--/"P-Lei//JJ �i Type of Work: / i� �- D Est. Cost / r - --�Address of Work 4 f �c� V `-'t —Owner Name: C :kc\ • Date of Permit Application: 74/, _ _-- 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. Siened under penalties of perjury: I hereby apply for a permit a the agent Ap • • er: / V ate or Name Registration No. • OR: • Notwithstanding the above notice, I hereby apply for a permit as the owner of the above property: Date Owner Name