HomeMy WebLinkAboutBLD-93-726 'p"r, o. TOW OF YARMOUTH o F R` 1g3
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MAT ACME 5. •'{ -
cs,,4.,.�. )6cei Application fo a Permit to Build No. 7�k
11.1 ,1. . i 73
i
UPON FINAL APPROVAL �� 9' MAP P-.- LOT
FEE MUST ACCOMPANY THIS APPLIC?ION. DATE
The undersigned hereby applies for ape it to build 9 '7M3
accordingtothe following�specicaions /a
c�7tje ane of property owner a • s • .1 iI ��S �0
Address = i,.a�.t IP TIM1, In . aM.: M91 ,
2.Na�eofArchitect(ifany) I °° ° a'• �n - rvdIlTgl.
C3:f me of builder 1 _ AlI0 •ddress (5 Hnit PJn prVP1
4. License No. 1614) 79 K•1 L Tel.
5. Name of Mason Address
6. License No. Tel.
1 cConstruction address l S 1-1-enie e d Pl O[2.1 V c ui_ Li 'ry o f U
8. Date of subdivision Approval Flood
plain zone !' Distri
pp nect Kn �S`�
Zo
9. Private dwelling 0 Estimated d05tDO NOT WRITE IN THIS SPACE
10. Multi family 0 dO .OfdA� aa�Q� Type of room No.
11. Commercial 0 I -Kitchen
12. Other ❑ /6 1,4 L/ Dining Rm.
t�O. 0--v
13. No. of stories /0 ��� Living Rm.
O-v
Bed Rm.
14. Foundation — Full 0 Half 0 Crawl ❑ Slab 0 trg / 0 ire Set. Bath
15. Materials — Wood 0 Cement 0 Otler 0 Deck
16. Type of heat — Oil 0 Gas 0 Electric 0 Other 0 Closed porch
Family Rm.
17. Garage — 1 ❑ 2 ❑ Sun room
18. Swimming pool - Size - Garage
19. Storage shed — Size /OK ' Shed /A/( I
. 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 I - From rear lot Ii. = Side line
25. H.I.C.R. No.
vy% ilk LOT RELEASED BY Signatu : I er`.i a -/.'�'/, AL 1,a
PLANNING BOARD Address l5 111 erY1e n n . r` t V e
Date Ul „da-Y`m (1lan t 14cL. 0oZ -T3
Des "/. b3
TOWN OF YARMOUTH
BUILDING DEPARTMENT
HOMEOWNER LICENSE EXEMPTION
i ti ,i
PLEASE PRINT:
DATE q ' Iti -413
JOB LOCATION }1 i u m n t
t5 STREETp �r�
ER Cannon
ADDRESS S SECTION
�OF TOWN
"HOMEOWNER" R O6eEr-� an n o HOME PHONE 5 - I'{ WOi �HONEacg 6 6
NAMPRESENT MAILING ADDRESS Fair0 ucA SO GU
CP n1 (
CITY1R TOWN M STATE ZIP COD2—
E
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 DEPA' -li
MINIMUM I ECTION PROCEDURES AND REQUIRE-
MENTS AND THAT HE/SHE CO LY WIT SA D PROCEDURES AND REQUIREMENTS.
HOMEOWNER'S SIGNATURE j c(-- fe,1 1t.� ---i(J
APPROVAL OF BUILDING 0 ' ICIAL
INSURANCE CO RAGE:
I have a cure lability Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes No ❑
If you have checked,Les, please indicate the type coverage by checking the appropriate box. •
A liability Insurance policy 0 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.
Check one:
Owner 0 Agent 0
Signature of Owner or Owner's Agent
•
Suggested Affidavit for Home Improvement Contractor Permit Application
For Office Use Only , NAME OF CITY/TOWN
Patn1t No.
Date
AFFIDAVIT •
Home Improvement Contractor Law
Supplement to Permit Application
MGL c.I42A requires that the"reconstruction,alteration,renovation.repair,modernization.conversion.inprovement,removal,demolition.
orconstruction of an addition toanv pretsistinG owner-occupied buildingcontaining 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 cenain exceptions,along with other
requirements. C L
Type of Work: J f` J -
--Est. Cost
Address of Work IS tM U on Dr ( v
Owner Name: a (0 Com' v C Cub levc_rn
Date of Permit Application: 9 a-1 -
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 ••
.�wner 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: •
Notwithstanding th• arove no ice, I hereby .pply or a permit as the owner of the above property:
Date Owner Name
PLOT PLAN
•
• FOR• LOT If ' •
Yoi„
• Indicate location of garage or accessory building
Additions with dashed lines
Sewerage disposal (cesspool)
Well 0
...• I • Cte-° 1,3 0 1•3
tti4
I (lot "�.� " ft. rear) I
Abuttor's 'Abut
Name I� �- Name
Lot u • I Lot n
• r
' REAR YARD )
If this is a If t
corner lot, y ft. `� • corn
•
write in name ia,tit
of street. I 1)<. name
r � _. o ..other
•P 0 streE
o ro
Kobe,-k- •
e^ wJ SIDE YARD . SIDE YARD
Nunn)n)E • HOUSE
FT. 0 0 FTr� •
• V Yi
• • • 4
• I ' .
SET BACK
• A
• • ft.
o
I
•
(lot 7� ft. frontage) ..
/ i-kme n 0 Dr; J e
/
\ / (NAME OF STREET)
•
/ -Information ://- • /•
Supplied by
/ \ /
•
_ COMMONWEALTH OF MASSACHUSETTS
__E�r DEPARTMENT OF INDUSTRIAL ACCIDENTS
'. i• 600 WASHINGTON STREET
games J Camooet, BOSTON, MASSACHUSETTS 02111
•
comm ss onet ( WORKERS' COMPENSATION INSURANCE AFFIDAVIT •
1, 'v i Jc, V is L l 1 o
(licensee/permittee)
• with a principal place of business/residence at: ��
(� �enAQ on • p r[v -e--- l� ,O, ynA axA k& 0x673
(City/Stam/Zip)
do hereby certify, under the pains and penalties of perjury.that:
[) 1 am an employer providing the following workers' compensation coverage for my employees working on this
job.
Insurance pony 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: • • -.- 1 .
•
Name of ContractorInsurance Company/Policy Number . .... .. .
Name of Contractor Insurance Company/Policy Number
Name of Contractor Insurance Company/Policy Number _
G m a homeowner performing all the work myself.
NOTE:_Pleue 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 iecure coverage as required under Section 25A'of 1AGL 152 can lead to the imposition of criminal penalties
consisting of a fine of up to SI 500.00 and/or imprisonment of up to one year and civil penalties in the form of a Stop Work Order and a
fine of$100.00 a day against me., ,
Signed this `Sri/ t day of —'2 C tv\ke 93
3
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Lic.^sc%Permr,.ct. LicensoriPermir,or