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Home My WebLink AboutBLD-93-740 �Y� .ys. Y o TOWN OF YARMOUTH 9-QM oA . ""' . ) '• MATTACME 5 es,,Cl W,% ApplicationLfor a Permit to Build No. 1 UPON FINAL APPROVAL 1 q3 9 MAP �,� LOT X - 76 • •FEEMUSTACCOMPANY THIS APPLICATION. DATE 9/3o 19 93 The undersigned hereby applies for a permit to build 9i3%3 acording to the following specificationsvl Gesn; Name of property owner o,( i,., ' G/i)sk^ / Tel. Address 5 Qe 9 �-/si, ✓ ',v7- J? c/wexeat Ej ,u/t • /3Name of Architect(if any) / Tel. � (i. Name of builder Piams c 41/4 .A.5)Address p. 0 S e 6 A. , N.. t Q' 4. License No. 7/��f Tel. 36, - 39°7 Q4.. 5. Name of Mason Address 6. icense No. Tel. . Construction address y/ ,/ ,i' /! if '4j. Yd ',c&,rd if ,F District a-S 8. Date of subdivision Approval plain zone rt 9. Private dwelling 0 Es imated Cost DO NOT WRITE IN THIS SPACE Type of room No. • 10. Multi family 0 oZ O0d a lia le-P4miext. 1 • 11. Commercial ❑ SiAre 1 . , Kitchen 12. Other ❑ Dining Rm. 13. No. of stories .iii.. 4 ,4 35 Crtj Living Rm. 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 0 Gas 0 Electric 0 Other 0 Closed porch 17. Garage — 1 0 2 ❑ Family Rm. 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 line Side line 25. H.I.C.R. No. 1/61-7G3 - LOT RELEASED BY Signature / - �� PLANNING BOARD Address Date TOWN OF YARMOUTH I BUILDING DEPARTMENT • • _ CONSTRUCTION SUPERVISOR FORM • PLEASE PRINT: . . ' ' JOB LOCATION: %( • g • //4 / to v/"/, .`-ol As/ NUMBER `` STREET . VILLAGE • OWNER OF PROPERTY: - / /-<. f277./. ./_./t.62-5/ ' CONSTRUCTION SUPERVISOR: 77�D.nM 5 (wit) , , 7/020) X'd0-�S -Yrs1 . NAME LICENSE NO. PHONE NO. ADDRESS: • P• it. Sd :5--e49if?e04/ dm✓l ' �G�llt•�i. - 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 BE 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 DE'OLITION AS REGULATED BY SECTION 109.1.1 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. l' ' ' "' . : • I HAVE READ AND UNDERSTAND MY RESPONSIBILITIES UNDER THE RULES AND REGULATIONS ,FOR _ICENSING 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. ' ': INSURANCE CO RACE: .. . • . "';•T«« I have a ctrren :ability insurance policy or its substantial equivalent which meets the requirements of Math-152 . ".:. `^ • Yes - No ❑ :: .... .. If you have checked is please indicate the type elver-age by checking the appropriate box y:' A liability insurance optic/ 0 Other type of :ademndy 0 •• • - ,Bond 0 _ • OWNER'S INSURANCE WAIVER:I am aware that the rr_nsee does rot have the insurance coverge requirec:tt Chapter152 of the Mais: General Laws, ano that my signature on m:s permit :colic:Mon wares this requirement Check one: •• ,' Owner' Agent 0 ' Signature m Caner cr Owner s Agent • I SIGNATUR�`� �� BUILDING OFFICIAL APPROVAL: `2' __�4 COMMONWEALTH OF MASSACHUSETTS rf: — `Gt' • DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 WASHINGTON STREET names Campoeu BOSTON, MASSACHUSETTS 02111 • Cpr^ntsswner WORKERS' COMPENSATION INSURANCE AFFIDAVIT 1 • /7164,13S- /az/0 7/4182?/CA' zc d( ioe✓ QX�( (licensee/permittee) • with a principal place of business/residence an (City/Sure/Zip) • do hereby cerrify, 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. [ ] I am a sole proprietor. general contractor or homeowner(drde 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 of Contractor Insurance Company/Policy Number .. - Q I am a homeowner performing all the work myself. - NOTE_ 'leue 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,sea. 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 lnsuranoe for overage 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 SI 500.00 and/or impr• on... t 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 th r day of ;7 d , 19 9 _ . -., License.:Pe.....-__ Lic:nso:;P:rmi-tr • • _ • . s uggested 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. orconstruction of an addition to anv pre-existing owner-occupied building containing at least one hut not more than,four dwelling units....or to structures which arc adjacent to such residence or building"be done by registered contractors,with certain exceptions,along with other requirements. Type of Work: /4,10/"/ 4.17,1/4'16` Est. Cost „i Address of Work y(, Z ,66Z-j' /6 Owner Name: 2607/ t 'c t/ Date of Permit Application: ?�7 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. Siened under penalties of perjury: \ I hereby apply for a permit as the agent o owner: l2 r S) /303 a t S lgeA //DIC5 DContractor Name Registration No. OR: • Notwithstanding the above notice, I hereby apply for a permit as the owner of the above property: Date Owner Name ApP� x�� fry,�3 5 e.,111,0AV 5) BUILDING PERMIT if: /B �l GS: rte- �(,3 _ Aw.01 ✓41"r .2547165 'TELE. NO. : /�D "67S4f92DATE FILED:. �'i/�7�p LDG. SITE LOCATION: 0: 6 „enede /29 MAP If: y a LOT#; X7lo THE FOLLOWING INFORMATION OUTLINES THE PROCEDURAL STEPS REQUIRED TO OBTAIN A PERMIT TO BUILD, ALTER, OR ADD TO A STRUCTURE WITHIN THE TOWN OF YARMOUTH. THE BUILDING DEPARTMENT WILL DETER- MINE COMPLIANCE TO THE FOLLOWING (A) ZONING REQUIREMENTS (B) HISTORICAL DISTRICTS (C) FLOOD PLAINS ZONING. THE BUILDING DEPARTMENT WILL BE RESPONSIBLE FOR ASSISTING THE APPLICANT THOUGH THE FOLLOWING DEPARTMENTS: RESIDENTIAL AND/OR COMMERCIAL BUILDING WATER DEPARTMENT: DETERMINES COMPLIANCE OF WATER AVAILABILITY. ENGINEERING DEPARTMENT: DETERMINES COMPLIANCE FOR PARKING AND DRAINAGE. CONSERVATION COMMISSION: DETERMINES COMPLIANCE TO WETLANDS ACTS, I.E. : IF LOT(S) BORDER ANY TYPE OF WETLANDS, STREAMS, PONDS, RIVERS, OCEANS, BOGS, BAYS, MARSH LAND, ETC. HEALTH DEPARTMENT: C DETERMINES, COMPLIANCE,TO STATE AND TOWN REGULATIONS,' I.E. : REQUIRE- MENTS FOR SEPTAGE DISPOSAL AND OTHER PUBLIC HEALTH ACTIVITIES. FIRE DEPARTMENT: "' ; DETERMINES COMPLIANCE TO STATE AND TOWN REQUIREMENTS FOR PERSONAL SAFETY, PROPERTY PROTECTION, I.E., SMOKE DETECTORS, SPRINKLER SYSTEMS, ETC. THE FOLLOWING DEPARTMENTS MUST SIGN OFF, IN, THE RESPECTIVE ORDER, PRIOR TO BUILDING INSPECTOR ISSUING THE REQUIRED BUILDING PERMIT: REVIEWED BY: 1. WATER DEPARTMENT . DATE: N/A: 2. ENGINEERING DEPARTMENT: DATE: N/A: 3. CONSERVATION: DATE: N/A: 4. HEALTH DEPARTMENT DATE: N/A: INDUSTRIAL AND/OR COMMERCIAL PERMITS 5. WIRING INSPECTOR: DATE: N/A: 6. PLUMBING INSPECTOR: DATE: N/A: 7. FIRE DEPARTMENT: DATE: N/A: • PLEASE NOTE ALL STUMPS AND/OR BRUSH MUST BE DISPOSED OF AT AN APPROVED SITE. A SIGNED RECEIPT FROM THE DISPOSAL SITE MUST BE SUBMITTED TO THE BUILDING DEPARTMENT PRIOR TO ISSUANCE OF THE BUILDING PERMIT. • COMMENTS: • 3LM/89