HomeMy WebLinkAboutBLD-93-738 �•Yq
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$Of , ' TOWN OF YARMOUTH r9�a 93
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�,,"t „, / Application for a Permit to Build No. 133
UPON FINAL APPROVAL 9c �3
� MAP q 7 LOT 571
FEE MUST ACCOMPANY THIS APPLICATION. DATE s?et- 3C) 19 �t 3
The undersigned hereby applies for a permit to build C f 3019 2'
ac,ording to the following specifications
V9. Name of property owner S•_ .. - . % •_u- _ Tel.
S a. k '
Address ► _
Lmeofbuilder
meofArchitect(ifany) - / c7Zi . Tel.
L .: . :n., a. I. 1 W441 •ddress 03 qD 9 tad 3 st c-Devtntio
4. License No. /D CMS Tel. 3IRC '707 CC
5. Name of Mason Address
6. Lnse No. Tel.
L7:
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43,
COMMONWEALTH OF MASSACHUSETTS
• e DEPARTMENT OF LNDUSTI2IAL ACCIDENTS
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600 WASHINGTON STREET
James Campoei BOSTON, MASSACHUSETTS 02111
morn:ss+one WORKERS' COMPENSATION INSURANCE AFFIDAVIT
I, M(6 A kkr n *IAA?Mg E' WIp,-tVic
(licensee/permittee)
• with a principal place of business/residence at:
cQa tf\V : SA- Po .q 04 ehNAis NOS Oat, 3q
(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.
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Tc•nt1/4) ` ((X�( nk4.C,ili061/� (off( to)Qiu, k4ob9 q3 •
Insurance Company Policy Number
[J 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. --•-t -•• ..
Name of Contractor Insurance Company/Policy Number .: .
Name of Contractor - Insurance Company/Policy Number
Name of Contractor Insurance Company/Policy Number -
Q 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
dweiiine of not more than three units in which the homeowner also resides or on the grounds apputsenant thereto are not generally
considered to be employers under the Workers'Compensation Act(CL C. 152.sect. 1(5)).application by a homeowner fora license
or permit may evidence the legal status of an employer under the Workers'Compensation Act
1
understand that a copy of this statement will be forwarded to the Department of Industrial Accidents Office of Insuran&for coverage
• verification and that failure to secure coverage as required under Section 25A of NGL 152 can lead to the imposition of criminal penalties
consisting of a fine of up to 51500.00 and/or imprisonment of up to one year and civil penalties in the form of a Stop Work Order and a
fine'of S 100.00 a day against me. / /
Signed this ( 36 iCOJ R//l&4.t. day of 9l/.�7/ , 19 9 3 •
Licer.s:e.Pernt: __ ...__.:ouPermt-or
Suggested Affidavit for Home Improvement Contractor Permit Application
For Office Use Only NAME O ITY/I.OWN •
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Permit No. 0.t—M0 •
Date
AFFIDAVIT •
Home Improvement Contractor Law
Supplement to Permit Application
MGLe.142A requires that the"reconstruction,alteration.renovation.repair.modernist ion.conversion.in provement,removal.demolition.
or construction of an addition to anv pre-existing owner-occupied building 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: y1p a 0 con; Est- Cost tg50O : —
Address of Work S(., 4.10ri1 In tel in is Qct_ S, LQptllYYinee
Owner Name: TO_•r u ce �y�s c,�n-!I
Date of Permit Application: ?/z 9/93 - -
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:
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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.
Siened under penalties of perjury:
I hereby apply for a permit as the agent of the owner:
5fr9/qs tAVbta - lkrrti tkikt L?nt $ / osf 23
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
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In accordance with the provisions of MGL c 40, S 54, a condition of Building Permit •
Number is that the debris resulting from this work shall be
disposed of in a properly licensed solid waste disposal facility as defined by MGL c 111, S
• 150A.
The debris will be disposed of in:
�47112..iel flfrIty tr 74
(Location of Facility)
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Signature of Permit Applitaaeil.7���
ate