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Home My WebLink AboutBLD-93-753 .s- r, e TOWN OF YARMOUTH PAM 0 Pm - —,3 � MA;tn.'.CS 44� cs,,4�«a.,,e.�c.. Application for9P ermit to Build No. 753 UPON FINAL APPROVAL 10e MAP V LOT /7 FEE MUST ACCOMPANYTHIS APPLICATION. DATE Oe-4- S 19 3 The undersigned hereby applies for a permit to build / D,/ ,/93 according to the following specifications 1. Name of property owner 1-1 ar? L e n t L.. Tel. Address 9 S Pn,.&•• s+ S .'e.,. 1 M A 2.Name ofArchitect(ifany) Tel. _ 3. Name of builder C,c.rr ? 1-1erri I I Address 3 ► L Wia1c..4 r-a- 4. License No. C93 3 11,22 Tel. -StS- SS'6t 5. Name of Mason _Address 6. License No. Tel. 7. Construction address 9-s P 0,d, 4 . Flood �0 District 2-q a 8. Date of subdivision Approval plain zone Zone 9. Private dwelling 0 Estimated Cost DO NOT WRITE IN THIS SPACE Type of room No. 10. Multifamily 0 31 a d0% an) ,% RC p rrtrts 11. Commercial 0 .)67A4, st,&41 ,— / I c73 ,\ • + Kitch n 12. Other ❑ Dining Rm. 13. No. of stories i(i td fie- , Living R Rm. k_r m. t` Bed Rm. 14. Foundation - Full ❑ Half 0 Crawl ❑ Slabbk% 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 Am. Sun room 18. Swimming pool - Size Garage 19. Storage shed — Size Shed 2a 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 n$ 41S r LOT RELEASED BY Signature C --4-1-c.id/' , M[Cr N PLANNING BOARD Address Date ' t_ t - COMMONWEALTH OF MASSACHUSETTS r,. `ct • DEPARTMENT OF DIDUSTRLSL ACCIDENTS • • • 600 WASHINGTON STREET sanies Camcoeu BOSTON, MASSACHUSETTS 02111 • • comm:ss,oner WORKERS' COMPENSATION INSURANCE AFFIDAVIT • 1, c.rr1 (e\ ort (licensee/permhtee) • with a principal place of business/residence at: • • (City/State/Zip) do hereby cerriry, under the pains and penalties of perjury,that•. [J 1 am an employer providing the following workers' compensation coverage for my employees working on this job. Insurance Company Policy Number (j 1 am a sole proprietor and have no one working for me. [tjA am a sole proprietor, general contractor or homeowner (circle one) and have hired the contractors listed below who have the following workers' compensation insurance polider •, • ••• KPrrl.1 ( ( ) OV Name of Contractor Insurance Company/Policy Number . . •__...• Yn 11 t Li l ` > �r � ` `� Name of Contractor - . • Insurance Company/Policy Number ::t. • 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 is which the homeowner also resides or on the grounds appurtenant thereto are not generally considered to be emoloyen under the Workers' Compensation Act(GL C.152.sect. 1(5)).application by a homeowner for a license Of 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 Accidenu'Office of Insunn&for coverage verification and that failure to secure coverage as required under Section 25Aof MGL 152 an lead to the imposition of aiminal penalties consisting of a line of up to 31500.00 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 • day of , 19 a : a • TOFTN OF YARMOUTH - - • BUILDING DEPART:ENT CONSTRUCTION SUPERVISOR FORM ' , PLEASE PRINT: ' ' . • • - JOB LOCATION: • clI d�(SS •�cC NUMBER • . STREET VILLAGE ,OWNER OF PROPERTY: ' h ear 6 • n C� CONSTRUCTION SUPERVISOR: • S c 2 k e S c 1 l I • ' 3 ZS-?To C . NAME LICENSE LICENSE NO. PHONE NO. ADDRESS: M i ,,. .<Oa, ,tt... .0 #v CLL. ` Cd 4 . p A LICENSED DESIGNEE: .i< „e.#L. h Cie 6 I . (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, REPMOVAL OF D DMOLITION 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 DEPARTENT. ' ' ' ' : • • • ' . I HAVE READ AND UNDERSTAND MY RESPONSIBILITIES UNDER THE RULES AND REGULATIONS %FOR LICENSING 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. . • • INSURANCE COVERAGE: : ` ' : . . . . ��, I have a c trrent liability insurance policy car its substantial equivalent which meets the requue nents of Math.-152 :?,:" • . Yes 'J�/. . ::No ❑ .. _ If you have checked ves, please indicate the type cavern: by checking the ap.rcpriate box: _ : .' A liability insurance pcacy ad • O:her type of :.ndemnity 0 ..• • - Bond 0 .....:.. .t__ OWNER'S INSURANCE WAIVER: I am aware that the licensee deer: net have the insurance coverage required`y Chapter 152 of the Mass. General Lows. ana that my signature on tars permit cpplication waves this requirement • Check one: • a A4 nl.,4„0,,,KJ • Owner❑ Agent 0 - S:gnature or C..ner ct cn. liras Agent SIGNATURE:` \- ,Lk BUILDING OFFICIAL APPROVAL: ' Suggested Affidavit for Home Improvement Contractor Permit Application , • For orrice Use Only NAMEgds OF CITY/TOWN Permit No. "1" C no Uk- Date • AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application MGL a 1424 requires that the"reconstruction.alteration.renovation.reoair,modernization.conversion,improvement,removal,demolition. or const ruction of an addition to any preexisting owner-cxcuoied 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: K.e.roor trc Est. Cost oUu , Va +OwneAddress of Work 9 S Po ..,e( s4- Owner r Name: R or a L_i NcL Date of Permit Application: d c:12 5 l 9 5 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 hcrcby 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. Id2A. Signed under penalties of perjury: I hereby apply for a permit as the agent of the owner: I0 ) S1n (3crc t-trrbt ) ( oRCIS Date Conkao ctor Name Registration No. OR: • Notwithstanding the above notice, I hereby apply for a permit as the owner of the above property: Date Owner Name .