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HomeMy WebLinkAboutBLD-93-737 /$47,: Ts ;`?8 TOWN OF YARMOUTH 9 3190 ` MAATCMEES at.1 '�° oIS ' Applicaty ffor a Permit to Build No. '737 UPON FINAL APPROVAL I /307-) MAP G 0 LOT 4 -1) -q. FEE MUST ACCOMPANY THIS APPLICATION. , , A DATE S 2Pr 5o 19 9 S • The undersigned hereby applies for a permit to build "9/3DM VNamerding to the following specifications -of property owner \\o2-Pa! Le Lc t+ Tel. 3941- tfa lig Address so ::50-r et 5 2ameofbuilder ameofArchitect(ifany) Tel. r7 �o,ik'�cE l3 LD co . _Address -r ° t rot ✓N.vh.ws i4A 4 4. License No. ra. 655-1 rl `G Tel. 42 I • 9 39 5. Name of Mason M / AAddress u /4- 6. License No. u Ire- Tel. ° l k- . A. Construction address Sa °°7oE c. ' . 5• rRem°va- Flood Districtya 8. Date of subdivision Approval plain zone C- Zone T 9. Private dwelling 0 Estimated Cost DO NOT WRITE IN THIS SPACE 10. Multi family 0 t 3 co • g ,C o1/ Type of room No. 11. Commercial 0 A, i• , ., nice4 l / LgY.re Yar Kitchen 12. Other ❑ To CeihF _Dining Rm. Living Rm. 13. No. of storiesBed Rm. 14. Foundation — Full 0 Half 0 Crawl 0 Slab ❑ 5-;G� Bath 15. Materials — Wood 0 Cement 0 Other 0 Deck 16.Type of heat — Oil 0 Gas 0 Electric ❑ Other 0 Closed porch Family Rm. 17. Garage — 1 ❑ 2 ❑ 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 lin- / Side line 25. H.I.C.R. No. LOT RELEASED BY Signature ©r, • / PLANNING BOARD r Address 6514 6o z Date - 770.-c4 J )1t 44.4, :71e-a- 0 24.0 • `" COMMONWEALTH OF MASSACHUSETTS P_e5 .6', DEPARTMENT OF DIDUSTRIAL ACCIDENTS ' 600 WASHINGTON STREET • times Camooeu BOSTON, MASSACHUSETTS 02111 ' Comn:ss one WORKERS' COMPENSATION INSURANCE AFFIDAVIT • •I, --ill .:t A S "CS . ,') • lin:iii.' /CC" e �ove10E I-3cb -• Cb . (I i censee/permittee) • with a principal place of business/residence ar. [..- !__.c� . ri;;, i.-, i;; . 3 :ilN.:C-S i'ti o 24 SUFI (Ciry/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. • "7/6/JP- , 50 - a 5/ cv 851/7 Insurance Company Policy Number [) I am a sole proprietor and have no one working for me. 1-,'[} 1 am a sole proprietor,genera] contractor or homeowner (circle one) and have hired the contractors listed below who have the following workers' compensation insurance policies: - - • -- /,J% i- .4..)/1-- Name of Contractor ' Insurance Company/Policy Number . Name of Contractor -. Insurance Company/Policy Number •- . : - • ._ .- - < it ./- 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 Insuran(z for coverage verification and that failure to lecure coverage as required under Section 25A of MGL 152 an lead to the impoiition of criminal penalties consisting of a fine of up to$1500.00 and/or imprisonment of up to one year and civil penalties in the form of a Stop Work Order and a fine of 5100.00 a day against me:_____.----.7—, ' ; to po- Signed this /ii"P,j•-V ,/i/�t.-I— day of . - 3a , 19 93 ,-, V — , Lic:t :::P:rtt: :: Licensor Perms-... r TOWN OF YARMOUTH • BUILDING DEPARTMENT . • CONSTRUCTION SUPERVISOR FORM PLEASE PRINT .• JOB LOCATION: SJ . JO`(Cc ` t . 5 . 4/41, G7JNrlf j'M -„ : NUMBER STREET. _ VILLAGE , OWNER OF PROPERTY: - •J:V L.t 21L C H�7 n • • : - CONSTRUCTION SUPERVISOR: 4:•-•�l45 'c� ;Jt2lCtl 0.55 1rf$ �Z8.73q NAME LICENSE NO. - - PHONE N0. ADDRESS: /C S r:,,vS ." ��• /1/4/ �r/r�t S.-' "n4 • -ort.g' . LICENSED DESIGNEE: - ii /� ` (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, REIOVAL 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. ' :••)- 1, 2.16. "ALL BUILDING PERMIT -APPLICATIONS SHALL CONTAIN THE NAME,ISIGNATURE AND LICENSE N1IBER OF • • THE CONSTRUCTION SUPERVISOR WHO IS TO SUPERVISE THOSE PERSONS ENGAGED IN CONSTRUCTION,- RECON- STRUCTION, ALTERATION, REPAIR,-REMOVAL OF DE:OLITION 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 DEPART:ENT."":-- -- r -.' _. :`._ _, `a., I HAVE READ AND UNDERSTAND MY RESPONSIBILITIES UNDER THE RULES AND REGULATIONS ,FOR LICENSING CCI- ' 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. - - ,•„-`-'7.-A • >. - -„ -. - - ` ! :.Y : : r" `,.-. •. INSURANCE COVERAGE: `.c; _. - • - --•M y� •;,r.;; .._ . • I have a current liability insurance cli or Ps substantial e en w - - .require-tents—Not.-._ -;r.:::�U ; hl p cY - equivalent which meets the MGLXxt.152 • .,:_:r. _..,_,_ .„ -:.— - -:..Yu ❑ _.:�'_No ❑-f`. ' :.:;c:':._ ._�.- ; - w.a�:•»cc:r_�,;°�.;.,.. :tri.=�='L«;T.IrtF r:'i": ,:::•::• If you have checked es, please indicate the type caves8e by checkin theap;; priate A liability insurance pCicy® - Other type of:nde mnity❑ --<--_t3ond ❑ '-'' OWNER'S INSURANCE WAIVER:I am aware that the licensee does: rot have the insurance coverage riquire:_tv. Chapter 152 of the Maas- General Laws, ana flat my sigrn ature on ta:s permit application waives this requirerreet. • t/.// - OwnerJ Agent 0 • - • -- $ignature at et.neryr O+.net sge / - . SIGNATUR;.. / 15.4 --BUILDING OFFICIAL APPROVAL: f . V 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 toanv pre-existing owner-occupied building containing at least one but not more thanfour 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: f t c vet EtosnQG /E,1YE,C. Est- Cost /30a • Address of Work C7) :Th4cE 57 , 5. yetemevr. /11 /-- Owner Name: �-, w£L C S# Date of Permit Application: c/l'c /9 3 I hereby certify that: Registration is not required for the following reason(s): _Work excluded by law _Job under 51,000 _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 hereby apply for a permit as the a ent-of the ow•:r: 9i2:19 3 rGnrv /000 3O-- Date Contracr"Name Registration No. OR: Notwithstanding the above notice, I hereby apply for a permit as the owner of the above property: Date Owner Name