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Home My WebLink AboutBLD-93-730 of TOWN OF YARMOUTH ,'taPo„nM .os�`�;� Application E .- .mjfor a Permit to Build No. MD UPON FINAL APPROVAL ?cA:aq q3 MAP SZ LOT C-5- FEE MUST ACCOMPANY THIS APPLICATION. DATE 5t2PTt9 19 S3 The undersigned hereby applies for a permit to build 747/98 according to the following specifications 1. Name of property owner 097"#4ee ' J--17.0,79 0€C Tel. tna - S«G Address / y Th -9974 ' Coto n/ i.--f9 solew 2.Name of Architect(if any) Tel. 3. Name of builder_A-2}.ti1KY sre5 Address /41�oiCedo�v Ae 4. License No. Tel. -7, Bras/ G(/ >' 4'W a to 5. Name of Mason _ Address 6. License No. Tel. 7. Construction address / V71,1eA42-5T ('ivn—y I-/4 50 >4t92.lain District ►r- P-S 8. Date of subdivision Approval plain zone 9. Private dwelling' Estimated Cost 071.'13' DO NOT WRITE IN THIS SPACE q. ,% _ � ere Type of room No. 10. Multi family0 / zoo JAG 1 - zsi3 ,mss rrin,-1,2 11. Commercial 0 Pt' �f , Kitchen 12. Other 0 Tstail Zic. , reir_ l t -fir Dining Rm. 13. No. of stories / PBed Rmm H� ' 14. Foundation — Full 0 Half 0 Crawl 0 Slab 0 (ep/y 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 la 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 25. H.I.C.R. No. / of sol- LOT RELEASED BY Signature X— PLANNING BOARD Address /1M',n6i e4ovry Of Date GU yittene7nl' /jlh' Oa/i 73 f72ifg PES TOWN OF YARMOUTH BUILDING DEPARTMENT . CONSTRUCTION SUPERVISOR FORM " PLEASE PRINT.v --- JOB LOCATION: I • . ]5f-1e e ie€ 7,4,A . 2....1/21SD ›ode- . UMBER . STREETVILLAGE .OWNER OF PROPERTY: CA¢7Wi_p,on dl oiewee. CONSTRUCTION SUPERVISOR: NAME LICENSE NO. .PHONE N0. ADDRESS: .. . 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 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 DEPARTMENT. ' 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 BUILDING CODE. I UNDERSTAN: THE CONSTRUCTION INSPECTION PROCEDURES AND THE SPECIFIC INSPECTION AS CALLED FOR BY THE BUILDING OFFICIAL. — .. K-�..�J... . .i':' INSURANCE COVERAGE: = !have a current liability Insurance oli or its substantial - - i C 2 • ; / p cY equivalent which meets the regtrrements of MGL1Ch.152 :7471.1,1;5 -“: _- :•s�No O -�. _a�:.::a .:.� •: ..;..-_-',a_:.- . . . ----- � -_ -,-- �_.e •T:�-, -!4„1:,---,r.•;)-- �-- -. - - .-i1- . -- If you have checked ves, please indicate the type eweraSe by checking the apprcpriate bez "-----_? -:"`-":- �� . ;�. ' • ' A liability insurance pcficy 0 Other type of :idemnity 0 --- -:-!land 0 = ? _ ` OWNER'S INSURANCE WAIVER:I am aware that the r:r_nsee deet rot have the insuran:e covergeuuereqmuired r C.apter152 of the Mass: General Laws. ana that my sign::ure on the permit acplicaticn wanes this reqeri • • Check one: • . . • Owner° Agent 0 • " - Signature of Owner or Owntr s Agent i SIGNATURE: iy�/�ir BUILDING OFFICIAL APPROVAL: e Suggested Affidavit for Home Improvement Contractor Permit Application . • ForOffice Use Only - NAME OF CITY/TOWN Permit No. Date AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application • MGL c.I42A requires that the"reconstruction.alteration.renova lion.repair.modernization.conversion.inprovement,removal.demolition. or construction of an addition to anv pre-existing owner-occupied hmldim,,containing 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. 'Type of Work: ee Est. Cost/2-90 Address of Work leZ-71 S 1 X -z Owner Name: CA2-Y t =eov /..-7462G2r Date of Permit Application: /�i/ 557o 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. Signed under penalties of perjury: I hereby09727 apply for a permit as the agent of e owner: GlIZ-97j n /5.0 2-- Date Contractor Name Registration No. OR: • Notwithstanding the above notice, I hereby apply for a permit as the owner of the above property: Date Owner Name ,ice tCOMMONWEALTH OF MASSACHUSETTS DEI AR:MENT OF INDUSTRIAL ACCIDENTS • ,, ' r . 600 WASHINGTON STREET James Campoee BOSTON, MASSACHUSETTS 02111 Comn:ss,oner WORKERS' COMPENSATION INSURANCE AFFIDAVIT • I, FSIgn - f7I14�s (licenseelperminee) • with a principal place of business/residence an. . • • ) ltw 6Gefionv fif/ ,Y/f2' (CitylStateZip) 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. [ J 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 - Insuance Company/Policy Number - - .. Name of Contractor Insurance Company/Policy Number . - o lam a homeowner performing all the work myself. NOTEE_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;ecure coverage as required under Section 25A'of MGL 152 can lead to the impoiition of criminal penalties • consisting of a fine chip to SI500.00 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. - • Signed this pis// :�� day of , 19 Lic_rso::Perini