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Home My WebLink AboutBLD-93-745 4s- r fro TOWN OF YARMOUTH �q/,�v/ci3 O I4 —H' ?es;:"°"` _6 Application for Permit to Build No. �� axw.iw+� li UPON FINAL APPROVAL V✓ /� MAP 6 7 LOT Q,714 FEE MUST ACCOMPANY THIS APPLICATION. DATE ,;.+irr.4 19 't- The undersigned hereby applies for a permit to build /0 //93 according to the following specifications 1. Name of property owner tee foe. Go Men) /�// I. Address ik rNAe.eet0a.N(P Ro&& Wet'' Y4rw,00 2.Name of Architect(if any) Tel. 3. Name of builder M1 kP t1\t C oS r(e1L�Address 10 xuNt Jton, Avw- itil 4. License No. Tel. I so" ' Y`L""tO" ` 5. Name of Mason address 6. License No. Tel. 7. Construction address I9 Zs'tk tion ciesoct_ R.4L Ldes" Ya.inau District Flood40...a. )_�5._— a Date of subdivision Approval plain zone C- Zone in 9. Private dwelling 0 Estimated Cost DO NOT WRITE IN THIS SPACE 10. Multi family 0 „ZI100 94) ire,th r?r ,e,,,,,, Type of room No. '% :� ?H?t11 -oi torr re. O'Pei//2 11. Commercial 0 Sit .4 roec- Kitchen COD/I- _Dinin Rim 12. Other 0 IL-r4e'" raa veta't g e 13. No. of stories cock_ n` Living Rm. rc ere 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 ❑ 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 Fro ear I•t f : Side line 25. H.I.C.R. No. /031 .26 A / / LOT RELEASED BY Signature '4i' '�`'' PLANNING BOARD Addres• if bh , 'Os... 3ar Date Som,- Yaaw,ou* •• BUILDING DEPARTMENT ' CONSTRUCTION SUPERVISOR FORM • PLEASE PRINT: f "Rod ,I ' �Z • JOB LOCATION: 19 . Zade feiv fr eNcs.- �Rod We s4" % .,0L1h, '� NUMBER 1 ( STREET VILLAGE • OWNER OF PROPERTY: Sj,.eme C 1OldtA) CONSTRUCTION SUPERVISOR: Mike_ N`C-Cl,S k /0SJaC SAP-7.2 77 NAME t c Y �/ • LICENSE NO. PHONE NO. ADDRESS: } D Nua.'�'�ay4-e‘... ,q 4,4- vou7 hu-etin LICENSED DESIGNEE: V , (IF OTHER THAN SUPERVISOR) NAME LICENSE NO. • • 2.15 RESPONSIBILITY OF EACH LICENSE HOLDER: • .. :4)., 1•11/4 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 STAT BUILDING CODE AND THE DRAWINGS AS APPROVED BY THE BUILDING OFFICIAL 2.:5.2 THE LICENSE HOLDER SHALL BE RESPONSIBLE TO SUPERVISE THE CONSTRUCTION, RECONSTRUCTION, ' ALTERATION, REPAIR, RE:•!OVAL OR DE::OLITION INVOLVING THE STRUCTURAL ELF.DENTS OF BUILDING AND STRUCTURES ONLY PURSUANT TO TEE STATE BUILDING CODE AND ALL OTHER APPLICABLE LAWS OF THE CC?01ONWEALTH, 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 I:"_•!EDIATELY NOTIFY THE BUILDING OFFICIAL IN WRITING OF THE DISCOVERY OF ANY VIOL;TIONS WHICH ARE COVERED BY THE BUILDING PERMIT. :. :5. + ANY LICENSEE WHO SHALL WILLFULLY VIOLATE SUBSECTIONS 2.15.1, 2.15.2 OR 2.15.3 OR ANY , 1 OTHER SECTION OF THESE RULES AND RECLt- TIONS AND ANY PROCEDURES, AS AMENDED, SHALL 3E SUBJECT 1 TO REVOCATION OR SUSPENSION OF LICENSE BY THE BOARD. ALL BUILDING PERMIT APPLICATIONS SHALL CONTAIN THE NAME. SIGNATURE AND LICENSE NUMBER 0: (,/ .HE CONSTRUCTION SUPERVISOR WHO IS TO SUPERVISEE THOSE PERSONS ENGAGED IN CONSTRUCTION. RECON- ,4 STRUCTION, ALTERATION. REPAIR. Ran OF DE_`IOLiTION AS REGULATED BY SECTION 109.1.: OF THE ' COTE AND THESE RULES AND REGtt;TIO:;S. I:; THE EVENT THAT SUCH LICENSEE IS NO LONGER SUPERVISt: SAID PERSONS. THE WORK SHALL L421EDIATILY CEASE UNTIL A SUCCESSOR LICENSE HOLDER IS SUBSTITUTE: ON TEE RECORDS OF THE BUILDING DEPART:'ENT. I ;E READ AND UNDERSTAND MY REST CNSIBIL'—*:c liNDE. THE RULES AND REGULATIONS FOR LICENSING S::._CT:ON SUPERVISORS : ACCORDANCE :;I=": SECTION 109.1.1 0: TEE STATE BUILDING SE• THE CONSTRUCT E`;S-• N ?R C- THE _ CODE. I L3UIL_. 0 C _ URE AND SPECIFIC INSPECTION AS CALLED FOR EY •BUILD: OFFICIAL. , e INSURANCE CCVEF:.CE: • I have s c_^e••• I'a`th!1 ins;.•*- _ • j cele; cr ::s st:e:::Int::1 e: Yes No ❑ - -.•aye.^.t wn:.-.. :nett: :he .e:c:re.^.nts e! !.1GLitti.152 it you have ..._aed • t:e.. _, _ irci�.t :i.- _:•rer_',e by enemy; ..- --c.:_:u:e tux. ' A liability insurance - ci C:.:er bice N .semn::y 0 Hcnc 0 • CWNEA _ ;NSA:^,•!;C-' 'HAP:ER: Ira : vg._ .. _. :.`._ . :_. ._- .. .._ .7.:...::::::: e•:' r•:_:•e:iC _-•. - .,_•r_. `er:r7-• i_.vs. c_ ..._. -v -' ..,. :_rr.: :::.. _ E..e: ...:. tee:7.re.^ec.' 11bretCi,..wc... _-_ • [Suggested Affidavit for Home Improvement Contractor Permit Application • • ForOmce Use Only. -13AME O4 YIT CITOWN '• - Permit No. AFMOO . ' .. •.•• .. ..Date . _ • AFFIDAVIT ' Home Improvement Contractor Law . I ` Supplement to Permit Application - ; • MOLe.142Arequiresthatthe"reconsiruction,altention.renovation,repair,modernization,conversion.inprovement.reml,demolitionr or construction of an addition toanv pre•aisting owner iccuoied building Containing at least one but not more than fourdselling units....or .to structures which are adjacent to such residence or building"be done by registered contractors,with certain exceptions,alongwith other_•. ' requirements. . .. �i eDo Type of Work: CS'it,,,: d. /....L1-84) // Est. Cost .Address of Work I rt, ��yt,�,0,.,,_Lw( - l�f it gk T� ; Owner Name:' -tr./r (_' 6a/c&2ty , Date of Permit Application: 02 pi- aF// f,3 . • I v I . I hereby certify that: • • • •Registration is not required for the following reason(s): • , •< '• _Work excluded by law ' . • v< _Job under $1,000 _Building not owner-occupied • , Owner pulling own permit , ' ' _Other (specify) I ' Notice;is hereby given that: •t .:OWNERS PULLING THEIR OWN.PERMIT OR DEALING WITH UNREGISTEs. RED" t : • '+ CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE • •'' • • ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL' 4 • c. 142A. a a• ). • Signed under penalties of perjury: • • I hereby apply for a permit g/r,-> 07. cr: Date ,%.r; ac er ante • Registration No. •• , OR: i , Notwithstanding the above notice. I hereby apply for a permit as the owner of the above proper[}: F • Date Owner Name • . - TSEnUECO 1tOUE ItinOVIIEl>ti in;:. I. . -ti;p tlnhts IMPROVEMENT INC. 10 Huntington Avenue • CS YdiseDieti9. MN 0204 (6173)2C3-7277 It, OM 11 . '71J int . , i I • I COMMONWEALTH OF MASSACHUSETTS *J..- `cLa DEPARTMENT OF INDUSTRIAL ACCIDENTS c, 600 WASHINGTON STREET • James J Camper: BOSTON, MASSACHUSETTS 02111 • rpmm:Ss1Oner WORKERS' COMPENSATION INSURANCE AFFIDAVIT • f k2. i'L Ct & key (licensee/permittee) • with a principal place of business/residence an // ,/ 7 l�ca c�CAA..�+ �fc c S4 T22/, W 4 eS Da 6Gy (Gry/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. • 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 (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 • • Insurance Company/Policy Number • . . Name of Contractor Insurance Company/Policy Number .. _ • 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 Insurance for coverage verification and that failure to secure coverage as required under Section 25A'of MGL 152 can lead to the impoiition 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 5100.00 a day against me. • Signed this 3 a day of • EP . ' , 19 ¢3 - Alfr License.:Pe.^f-.. �cer s-