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Home My WebLink AboutBLD-93-720 t.YA 4.4tv% TOWN OF YARMOUTH pK (-6) 00 r: Q 194fr s wi .19 �,""T'"`. s ./ Application for a Permit to Build No. 7 O ,'kw.�.,m�f�.- UPON FINAL APPROVAL q a CAT -� MAP SLOT ' /6 FEE MUST ACCOMPANY THIS A PLIION. DATE 9 -022 19 93 The undersigned hereby applies.for a permit to build r/ . i/43 according to the following specifications // a 1. Name of property owner /%/'r /?M hplari . Tel. Address /o d'6 ,vo/$4 /,-1.446n ,r+/e-, �� a w2Tel. 2.Name of Architect(if any) a Name of builder .06 v.4 c.. MA-fey/SI- Address &d et,. /onA 1/45/4,-22 02457. 4. License No. 425/ 99 6 Tel. )2, 'Yn -9, ,a_ 5. Name of Mason _ Address 6. icense No. Tel. ✓7. Construction address 7 1,16-,114 414/r/ 1971" 5 y4,ene7 t4i Flood isr 8. Date of subdivision Approval plain zone G DZonteict hi 0 9. Private dwelling 0 Estimated Cost DO NOT WRITE IN THIS SPACE frt.P-12GRoa, Type of room No. 10. Multi family 0 700 Piing - j/C,ysrcHnc 47,emne- 1 11. Commercial p id „ ,;,,,v g, • Kitchen 12. Other 0 Dining Rm. 13. No. of stories 5� Living Rm. �`6.i D't 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 From rear lot line Side line i /25. H.I.C.R. No. • LOT RELEASED BY Signature ,..---•-- A/ �-:► _ PLANNING BOARD Address 20 a., / n,, //tlgS1j,-Pe Date TOWN OF YARMOUTH • BUILDING DEPARTMENT , • - --1 CONSTRUCTION SUPERVISOR FORDS PLEASE PRINT: /J • JOB LOCATION: 31 ' AJcrA /'44,4 5f • S yti'�ro"7J, NUMBER ��/ . STREET •VILLAGE ' OWNER OF PROPERTY: ' ..�2'Ar . • /2201)-ire? ,• L/ CONSTRUCTION SUPERVISOR: ,y2 Vie G.,./5/6/-1/1.,25 f •• •a S/•�'7� • y» -5% -Dw . NAE .. LICENSE NO. • PHONE NO. . . ADDRESS: • ' &e `v, /q.ir7 •/'1s e ,:a>>4 4-2L y9. • ' • •LICENSED DESIGNEE: ' • (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 IMMEDIATELY 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 ANTI REGULATIONS AND ANY PROCEDURES, AS AMENDED, SHALL BE 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 I}2IEDIATELY CEASE UNTIL A SUCCESSOR LICENSE HOLDER IS SUBSTITUTED ON THE RECORDS OF THE BUILDING DEPARTYINT. ' • ' ' I HAVE READ AND UNDERSTAND MY RESPONSIBILITIES UNDER THE RULES AND REGULATIONS ,FOR :ICENSING CC:I- STRUCTION SUPERVISORS IN ACCORDANCE WITH SECTION 109.1.1 OF THE STATE BUILDIIG CODE. I UNDERSTAZ: THE CONSTRUCTION INSPECTION PROCEDURES AND THE SPECIFIC INSPECTION AS CALLED FOR BY THE BUILDING OFFICIAL. . INSURANCE COVERAGE: I have a current liability insurance policy or its substantiae equivalent which meets the requirements of MGLth.152 Yes �`. :: : No ❑ _: _: It you have checked ves, please indicate the Cape c:verage by checking the ap::cpriate bcz A l ability insurance pdity • Cther type of :ademndy❑ •• Bond 0 • -- - • OWNER'S INSURANCE WAIVER:I am aware that the c pensee de_� re have the insurance coverage requirec:y Chapter 152 of the Mass. General Laws• ano that .ny signature on t',:s permit ::plication waives this requirement . • • Check one: OwnerO Agent❑ Signature or Caner cr Caner s Agent SIGNATURE: /9�e„ _474- , SZTILDING OFFICIAL APPROVAL: • --t` COMMONWEALTH OF MASSACHUSETTS . DEI`AICMThT OF INDUSTRIAL ACCIDENTS 600 WASHINGTON STREET • James o Camooei, BOSTON, MASSACHUSETTS 02111 • Comm:ss+ones WORKERS' COMPENSATION INSURANCE AFFIDAVIT • I, l> gEms. gGs^�dt/�S 4i3s� w/CI CO 447e7417 (licensee/perminee) • with a principal place of business/residence an (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 ik 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 overage 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$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 3100.00 a day against me. Signed this �✓ day of 9'--20. , 19 97 Lic.asat:Permrtor • ' " • Suggested Affidavit for Home Improvement Contractor Permit Application For Office Use Only - -- NAME OF CITY/TOWN - . Permit No. Date AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application MGL c.142A requires that the"reconstruction.alteration.renovation.repair,modernization,conversion.inprovement,removal,demolition. or construction of an addition to any prectistint;ownertxcuoied huildine rontainine 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 aceptions,along with other requirements. L Type of Work: 'fey'," '- -Est. Cost 700 . - .. Address of Work 3 7 A4ovii4 ,t,,„,n Owner Name: /e lr✓ nrc 4 „a-745n • Date of Permit Application: 9-aa — 93 I hereby certify that: Registration is not required for the following rcason(s): " • - - _Work excluded by law a�Tob under SI,000 _ .. ow-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 ar�nt he owner Date Contractorame Registration No. OR: . Notwithstanding the above notice, I hereby apply for a permit as the owner of the above property: Date Owner Name •