HomeMy WebLinkAboutBLD-93-760 ,$ s r% TOWN OF YARMOUTH X4&/9.3
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•H "4«a:o+,. . Application for a Permit to Build No. 76V
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UPON FINAL APPROVAL /0MAP 7 r LOT TC. 0
FEE MUST ACCOMPANY THIS APPLICATION. DATE ___/2371..__ 19 73
The undersigned hereby applies for a permit to build i//73
accor ing to the following specifications
. Name of property owner /41V eeto t- Jo A-v r Se Ri p v . Tel. 7 71-3/!f 6
Address 32 1pvta'Aii Why 5 yAicAi,N?ti
2.Name of Architect(if any) Tel.
G3.'Name of builder cow U t 2- Address 77 Tin r D.,v*, w.h y'
4. License No. 0/ZO/i 6 • Tel.
5. Name of Mason Address
6.License No. Tel.
7.
t� 'Construction address .37 T v s a I iv IN 11.y S• yhrMorir it
Flood District
8. Date of subdivision Approval plain zone C.— IC Zone - V O
9. Private dwelling 0 Astimated Cost DO NOT WRITE IN THIS SPACE
-1;1 ct /5(04.0 9Type of room No.
10. Multi family 0 it 2 co, o Gteem,VthflvH
11. Commercial 0 �7r Koo`J z N Kitchen
12. Other 0 ei` 4-`Z -Dining Rm.
13. No. of stories 3,5 cc) 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 ❑ 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
2a 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. /0 73? 7
LOT RELEASED BY Signature 47 gay,- Oita:
PLANNING BOARD Address /re /➢`A9idz:pLv 7)1,-
Date 1&ir 1/r4N -noun nn
TOWN OF YARMOUTH
* - - "-. BUILDING DEPARTMENT
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
vAT�E Oe.r t0 //
"Jrr/ 7
OB LOCATION ? I„ h a,ue It BevV/ Yin" AiovTJ/
NUMBER STREET ADDRESS SECTION OF TOWN
C-" EOWNER"Ju!AI CN?o -ILLL4,t/ r.04,4AU, 77i-71`0
NAME HOME PHONE WORK PHONE
. PRESENT MAILING ADDRESS Sftn/E
50078 1/ArMouTIt .rn, 0246 A
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
ATTACHED 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-
MENNTS AND THAT HE/SHE WILL COMPLY T SAID PROCEDURES AND REQUIREMENTS.
(,fOMEOWNER'S SIGNATURE 6//{ e�,lr /ce:"r
APPROVAL OF BUILDING OFFICIAL
•
INSURANCE COVERAGE:
I have aYes currre❑nt liability Ino once policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
If you have checked its, please indicate the type coverage by checking the appropriate box. •
A liability Insurance policy 0 Other type of Indemnity 0 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 Owners Aaent
•
.. .,
Suggested 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
MGLe.142A requires that the"reconstruction,alteration,renovation,repair,modernization.conversion,in_provement,removal,demolition.
or construction of an addition to any preexisting 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.
U
/./6-e of Work: 1 AI eg,c a e rt ti
xAT !U r mc vru Est. COSI /„2 St' '
d/dress of Work 27 T vni i tlr °dc1n finis y1 0 µOvral At el-
Wwner Name: 1/fpr4r nizv t Sc'kiv 6" Se !ii n v '
CA:Cat of Permit Application: /get /0 /997
I hereby certify that:
Registration is not required for the following reason(s):
_Work excluded by law
_Job under 51,000
,�By}+ifding 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.
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:
/o- fi P 7 /4 tt r <12
Date OCVner Name
P, = E • COMMONWEALTH OF. MASSACHUSETTS ,.__ _•
• °�0 - - . • DEPARTMENT OF INDUSTRIAL•ACCIDENTS
600 WASHINGTON STREET
games Camooei, BOSTON, MASSACHUSETTS 02111 •
comn:ssoner WORKERS' COMPENSATION INSURANCE AFFIDAVIT •
•
(111.111 K/?O — ♦(NAAl c SP .Ar/ t
(licensee/permi tree)
with a principal place of business/residence at:
Sriv?ft J r K.rut-tN M0266f�
(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.
•
Insurance Company Policy Number
H J I am a sole proprietor and have no one working for me.
[lm a sole proprietor, general contractoro •211118
•ne)and have hired the contractors listed below . :-
who have the following workers' compensation insurance po ides: -•• -=- '---
Name of Contractor Insurance Company/Policy Number . .
Name of Contractor Insurance Company/Policy Number • - -•
Name of Contractor Insurance Company/Policy Number
0 I am a homeowner performing all the work myself.
NOTE:.Pleue 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 lnsuranci for coverage
verification and that failure to;cure coverage as required under Section 25A'of MGL 152 can lead to the impoiition of criminal penalties
• consisting of a fine of up to$1500.00 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 9a7: day of C , 19 93
•
i, r ism
icer seei errnince. LicensoriPermittor