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Home My WebLink AboutBLD-93-724 t "; ,,7o TOWN OF YARMOUTH 01 ,Fe-tJ cibs/4s to... 0' Application for a Permit to Build No.427V__ UPON FINAL APPROVAL0� a 93 MAP 6 ? LOT -7 I FEE MUST ACCOMPANY THIS APPLICATION. /DATE - / 19f The undersigned hereby applies for a permit to build ql,7 �� according to the following specifications lige /1. Name of property owner 1_4/-/ P gni?r 7`- '/ Te .0 - i / Address 8 Cy/t. -avian WI / So"Air" ut4 /177 , .2 , 2.Name of Architect(if any) Tel. /a Name of builder 1--,,f/ /7' Sin -f. Address 4. License No. Tel. 5. Name of Mason Address 6. License No. Tel. /7. Constructioriaddress 6 Cht/. V4'ron ?J' SAY Flood District ,b 8. Date of subdivision Approval I n zgne C Zone �- 9. Private dwelling Y Esti ated Cost DO NOT WRITE IN THIS SPACE Klig /, . „,4/na . Type of room No. 10. Multi family 0 / ( `J6 I (Ds 11. Commercial 0 .4z. / /� _01 -V Kitchen 12. Other 0 Dining Rm. �'/'/ ° —'�y`�Q Living Rm. 13. No. of stories . /� a 0--;--13 ��' 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 ❑ Gas 0 Electric 0 Other ❑ Closed porch Family Rm. 17. Garage — 1 ❑ 2 ❑ Sun room 18. Swimming pool - Size Garage /19. Storage shed — Size 7 X /. Shed V')( 1 Z / 20. Stove — Wood 0 Coal 0 , Alterations 21. Size of lot: No. of feet front /0-0 No. of feet rear //51-0 No. of feet deep / 0 22. Size of building. No. of feet front /� No. of feet side Si No. of feet rear /y-L' 23. Distance from nearest building: Front Ft. side Ft. side Rear 24. Distance back from line or street /0e From rear lot line Side line /1 25. H.I.C.R. No. LOT RELEASED BY /Signature �,. PLANNING BOARD / Address 2 C 27 74 e7r7 ,i // Date __Vg/.../____ c - 114 dr , ii1D 07`h /V oa Y Suggested Affidavit for Home Improvement Contractor Permit Application For Office use only NAME OF CITY/TOWN Permit Na Date • • AFFIDAVIT Home Improvement Contractor Law . - Supplement to,Permit Application • MGL e.142A requires that the"reconstruction.alteration.renovation.repain modernization.conversion.i nprovemen t,removal,demolition. or construction of an addition to any pre-existing owner-occupied huildingcontaining 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. 9 /, .•\'Dip of Work: (/D/`/f -6�t4 /+ _/ � /� /Est. Cost \ Address of Work L ZI�,T, LT/370W 5 1$n'?r/YA fJA D��p� \ Owner Name: t e,/'/ 7 9 C'rt \ Date of Permit Application: /0.1o2 9� I hereby certify that: Registration is not required for the following reason(s): _Work excluded by law /-lob under SI,000 Building not owner-occupied \ 1-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: Notwithstandin. the above notice, I hereby apply for a permit as the owner of the above property: A 9 e lam" Dat' Owner Na TOWN OF YARMOUTH BUILDING DEPARTMENT ..... HOMEOWNER LICENSE EXEMPTION PLEASE PRINT:\ /� /p DATE 9/Gt g/ I L [ Phi JOB LOCATION NUMBERa' STREETed ADDRESS (.57o /SriCT ON OF TOWN \ "HOMEOWNER" , / 41121?/74- 91-127 /717 NAME HOME PHONE WORK PHONE \ PRESENT MAILING ADDRESS L.5 ,716.2____ 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 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 WILL COMPLY WIT)i SAID PROCEDURES AND REQUIREMENTS. `. HOMEOWNER'S SIGNATURE 3' / APPROVAL OF BUILDING OFFICIAL • INSURANCE COVERAGE: I have a currentJiability Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142. Yes ,{a`' No ❑ If you have eckedyes, please icate 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 Ma s. General Laws, and that my signature on this permit application waives this requirement r k one: Gil OwnerAgent 0 Signature r Owner of er's Agent • ___ COMMONWEALTH OF MASSACHUSETTS Rf CO DEI`AIr:1.1EIvrI' OF INDUSTRIAL ACCIDENTS 600 WASHINGTON STREET James Camooae BOSTON, MASSACHUSETTS 02111 • Comm:ss,oner WORKERS' COMPENSATION INSURANCE AFFIDAVIT •/ (licensee/permittee) • with a principal�iplace offbbusiness/residen ac Fr ry///C p TJ<7rO N1 �i � J A ruin l '4 74/ obie(City/Sp) 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 ( ) I am a sole proprietor and have no one working for me. H) 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 ftontractor Insurance Company/Policy Number . - I am a homeowner performing all the work myself. NOTE:.P1eue 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 Worken' Compensation Act(CL. 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$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 5100.00 a day against me. \Signed this q �oc/ �� day of , 19 dwdci5/14 Licer.se.,Pe.:n Lice.soriPermiaor PLOT PLAN -� FOR •LOT # ' • Indicate location of garage or accessory building Additions with dashed lines . Sewerage disposal. (cesspool) • Well • 4 � `i c i ,r. ...ft.• rear) I — — — Abuttor's l• -i /-r �9�J ! Abutt Name Name Lot ; .(.�J 4. • She .113' Lot n /tii/C0fa�ii,�, ,•i.:.' , RE 1,1%A RD !ai If this is a �, '/; • If tb corner lot, l • •ft. • corn( /c •/,:j. �p 4. writ write in name Y of street. .!•• I name ;� a othea A .p. v strec m CO •04 i c.- . . • • • SIDE YARD . SIDE YARD iki . •• HOUSE L a` / FT� • i 61• ✓ , 0 / < f,'b fl�yad � . tT BACK • . .\\: - . . . .ft. „ C (lot lM-6 ft. frontage) .• \ / \\ $ 6 j-f �. rQG1 , lid", \ \ / / 4 (GAME OF ,STREET) - / \ / \ • -information �` / \ Supplied by \ rig`i `/rli/'`s'"' / \