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HomeMy WebLinkAboutBLD-93-756 1. FYA , �� v ;s '�o TOWN OF YARMOUTH ©o 3 1 / f �' "w, ` $ $ Application for a Permit to Build No. 1 3" MAP �O LOT J -z 3 UPON FINAL APPROVAL ✓ FEE MUST ACCOMPANY THIS APPLICATION. DATE / n - (• 19 q3 The undersigned hereby applies for a permit to build /W923 according to the following specifications vc/7/1�-a \ 1. Name of property owner_ii )1trse M ifa.ey , (-2,Pnn../r- a Tel. 39y-yIX' .. NAddress — . _ / _ r A. e i¢ o z c e,y 2.Name ofArchitect(ifany) /0,-)t) Tel. \a Name of builder_gaM F,5,,, v ,_,- Address 4. License No. Tel. ' 5. Name of Mason Wog n f Address - 6. License No. Tel. \7. Construction address sy Ll SE.a-sn,o s LDR. So yepma o ru4,i/Flood ! District 8. Date of subdivision Approval plain zone Zone 2-y0 9. Private dwelling 0 Estimated Cost DO NOT WRITE IN THIS SPACE 10. Multi family 0 / 'Sp1571JG Type of room No. 11.Commercial 0 cLejtet t,fif ! " 00 Kitchen TA 12. Other 0 %if 3�, Dining Rm. 13. No. of stories / s1 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 ❑ Closed porch 17. Garage — 1 ❑ 2 ❑ Family Am. Sun room 18. Swimming pool - Size Garage 19. Storage shed-- Size B,X 8r Dc. & _c iorJ ro g \ 9 fig,- Mail . Shed /QtXIp. 20. Stove — Wood 0 Coal 0 Alterations 21. Size of lot: No. of feet front //L No. of feet rear qn No. of feet deep / / / 22. Size of building. No. of feet front 19-` No. of feet side i'i' No. of feet rear 2a Distance from nearest building: Front Ft. side 22 ' Ft. side Rear 1 24. Distance back from line or street 3 I ' From rear lot line 3 4 ' Side line 25. H.I.C.R. No. LOT RELEASED BY . \ Signature v PLANNING BOARD Address 515- ,AC &4> . . e� Date \ 5-,,rer..4-•I /4,4 n 7 c `y 34-y/f / PLOT PLAN r / . ` •; FOR LOT # _ ? '-r�i 0 i Indicate location of garage or accessory building Additions with dashed lines Sewerage disposal (cesspool) Well 0 I (lot ft. rear) I • Abuttor's I Abuttor's Name I Name Lot # I Lot # REAR YARD If this is a EC If this ' corner lot, I ft. corner 1 write in name write in of street. I name of is • I P other 0 b ro street. 4 SIDE YARD SIDE YARD 0_ FT_ ��/'� HOUSE 0-_�s/ _ FTp • • 0 I i 1 ,tETI Apdi"° , lit I 1 � _ . I ft. / faisra- ,T -1 A '0- -1,- Got. . / .(lot. . .,[/. 6 i ft. frontage) / V 5,/9 5,N s \ / \ / (NAME OF STREET) • / \ Information ) /� /� / \ \ Supplied by /011(i ( /r'° .-r et MARK NORTH POINT . .,• =„ • COMMONWEALTH OF MASSACHUSETTS - -- „ DEPARTMEN T OF NDUSTRIAL ACCIDENTS 600 WASHINGTON STREET • Dames Camooei, BOSTON, MASSACHUSETTS 02111 • Commissioner WORKERS' COMPENSATION INSURANCE AFFIDAVIT • • • (licensee/permittee)w• ith a principal place of business/residence ani • ReAr 1 .. 12de0 k /t (CO." R Ciry/Sure/Zip) do hereby certify, under the pains and penalties ofPer1urY,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. - - O - 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 . - X1 am a homeowner performing all the work myself. NOTE.Pleue be aware that while homeowner: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 lnsuranri for coverage verification and that failure to secure coverage as required under Section 25A'of 51GL 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 S100.00 a day against me. Signed this 717 T� day of SGT , 19 93 Licensee/Permit:et- LicensoriPermir:or TOWN OF YARMOUTH IJP ' ' BUILDING DEPARTMENT • `rHOMEOWNER LICENSE EXEMPTION PLEASE PRINT: DATE /0- 6 _ 73 JOB LOCATION 4-gi ;57,„ LI Ad / 22Lw ' c? /1_fw 44..[Le I NUMBER,gg- /STREET ADDRESS ` SECTION OF TOWN "HOMEOWNER" /LA, Qt1- fit �A"tell 399- Tie t NAME / HOME PHONE WORK PHONE PRESENT MAILING ADDRESS g D t. /?a exp 7 vr�o tax �''<! '07� 0 , 4_ 61 CITY OR TOWN STATE ZIP CODE THE CURRENT EXEMPTION FOR "HOMEOWNER" WAS EXTENDED TO INCLUDE OWNER- OCCUPIED DWELLINGS OF ONE OR TWO UNITS AND TO ALLOW SUCH HOMEOWNERS TO ENGAGE AN INDIVIDUAL FOR HIRE WHO DOES NOT POSSESS A LICENSE, PROVIDED THAT SUCH HOMEOWNER SHALL ACT AS SUPERVISOR. (STATE BUILDING CODE SEC- 109.1. 1) DEFINITION OF HOMEOWNER: PERSON(S ) WHO OWNS A PARCEL OF LAND ON WHICH HE/SHE RESIDES OR INTENDS TO RESIDE, ON WHICH THERE IS, OR IS INTENDED TO BE, A ONE OR TWO FAMILY ATTACH E D OR DETACHED STRUCTURES ASSESSORY TO SUCH USE AND/OR FARM STRUCTURES; A. PERSON WHO CONSTRUCTS MORE THAN ONE HOME IN A TWO-YEAR PERIOD SHALL NOT BE CONSIDERED A HOMEOWNER, SUCH "HOMEOWNER" SHALL SUBMIT TO THE BUILDING OFFICIAL, ON A FORM ACCEPTABLE TO THE BUILDING OFFICIAL, THAT HE/SHE SHALL BE RESPONSIBLE FOR ALL SUCH WORK PERFORMED UNDER THE BUILDING PERMIT. (SECTION 109.1.1) THE UNDERSIGNED "HOMEOWNER" ASSUMES RESPONSIBILITY FOR COMPLIANCE WITH THE STATE BUILDING CODE AND OTHER APPLICABLE CODES, BY-LAWS, RULES AND REGU- LATIONS. . THE UNDERSIGNED "HOMEOWNER" CERTIFIES THAT HE/SHE UNDERSTANDS THE TOWN OF YARMOUTH BUILDING DEPARTMENT MINIMUM INSPECTION PROCEDURES AND REQUIRE- MENTS AND THAT HE/SHE WILL COMPLY WITH SAID PROCEDURES AND REQUIREMENTS. HOMEOWNER'S SIGNATURE /,c),:_er tr. , 11 27/,,_. -. - / APPROVAL OF BUILDING OFFICIAL INSURANCE COVERAGE: I have a cu currentliability Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142. Yes g ' No ❑ If you have checked yes, please indicate the type coverage by checking the appropriate box. A liability Insurance policy [LIV Other type of Indemnity ❑ Bond 0 OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner 0 Agent 0 Signature of Owner or Owner s Aaent a Jet �ti -� • Suggested Affidavit for Home Improvement Contractor Permit Application For Office Use Only NAME OF CITY/I'O WN Permit No. rAq Mnorht N4 r Date AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application MGL a I42A requires that the"reconstruction,alteration.renovation,repair,modernization.conversion,inprovement,removal.demolition, or construction of an addition to any pre-existing owner-occupied building containing at least one hut 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: pi1arr-io,t) ro .5Or.n Est. Cost 3nno Address of Work S - _ Owner Name: /aft_7-Y74/{ /01,61,82/ KI C/'7,c', )F e L Date of Permit Application: /0 — 7 - 73 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 DQ 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 agent of the owner: ' 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