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Home My WebLink AboutBLD-93-761 IIrr �% TOWN OF YARMOUTH '.. MATT.i ` M 4' % % tZ 4 neg- Application for a Permit to Build No. UPON FINAL APPROVAL Yj d f d ' q3 MAP 2 LOT ///Z FEE MUST ACCOMPANY THIS APPLICATION. DATE /0 19 9 3 The undersigned hereby applies for a permit to build X903 accor ing to the following specifications . Name of property owner /h flU/i14 A data 149'-t Tel. 39Y .1/97' � // Address Ai 5 �n ..�—if 2 44. t' ameofArchitect(if any) . fro L U / • <Tel. // / 14-lame of builder _�7� �y , /A &'S Address 37<1/ tk—et 9r ilr3/�ak 4. License No. arecrCra003Y6Tel. ' 4a ' 3Kh-`t ame of Mason -rift S/,.Jsu Address 6. Lic nse No. Tel. G7(6onstruction address ;o5tC,41 /• 7320...C5/4 ve Flood ,l District 8. Date of subdivision Approval plain zone OM 6/) Zone /i.S' 23 . 9. Private dwelling 0 Estimated Cost DO NOT WRITE IN THIS SPACE E ,z/1 - /? .,eevr Type of room No. 10. Multi family 0 �1rad `� 5!Vat 14-.vrie,sn I&Fn/rr"c 11. Commercial 0 02)0 Kitchen 12. Other 1 Dining Rm. 13. No.of stories 4eace o--o 190nr Living Rm. Bed Rm. 14. Foundation — Full 0 Half 0 Crawl 0 Slab 0 AC; fit/• Bath 15. Materials — Wood 0 Cement 0 Other 0 ,S 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 From rear lot line Side line 25. H.I.C.R. No. .0®0 6'c / . LOT RELEASED BY L-Sig ature .i44v44' t (# f_/ 'Lc PLANNING BOARD . Address .��/-p (V _ $f (Jak-itS Date Gl1uVv I�/ /g/) , 0i-[. 3d • - 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 MGL c.142A requires that the"reconstruction.alteration.renovation.repair,modernization.conversion.in provement,removal.demolition. or construction of an addition to any pre-existing 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. Chalet �1 Type of Work: /7.G-fi0 Q C,�/� Ate. (..d 1�L2(.v� let �'-( Est. Cost fj-5`710• \ Address of Work (CJS � U�► �L sl'• �i hve.-' \ Owner Name: X (tj, tick • \ Date of Permit Application: /ON 93 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. Signed under penalties of perjury: I hereby apply for a permit as t e agent of the owner: \?4`_ __ �'-/ — /ec tat Da e Co tactor Name Registration No. OR: • Notwithstanding the above notice, I hereby apply for a permit as the owner of the above property: Date Owner Name TOWN OF YARMOUTH • BUILDING DEPARTMENT CONSTRUCTION SUPERVISOR FORM • PLEASE PRINT: .' 2 ' - `n, • • • ` JOB LOCATION: UUcS1 lJ7 VT�L U l�t17C/" i/C/ NUMBER • , . .' SIRE T VILLAGE . OWNER OF PROPERTY: ' • /3 of • we 4 �/ r / p SSG �- . , g� / CONSTRUCTION SUPERVISOR: I / ,� "�'� �� Y -�fr a"3�� . n {� `� AME /�j SLI LICENSE N . PHONE NO. ` ADDRESS: ' 3//,S �C!<y 6- • ai�k ,&e7S J CJ 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 COMYLETELY 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 • COt•LMONWE.ALTH, 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 DEMOLITION AS REGULATED BY SECTION 109.1.. OF THE CODE AND THESE RULES AND REGULATIONS. IN THE EVENT TEAT 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. " : '• • ' • I HAVE READ AND UNDERSTAND MY RESPONSIBILITIES UNDER THE RULES AND REGULATIONS ,,FOR .ICENSING CC:1- 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: ' - - ..Y.'Ii, ~ I have a curie liability insurance policy or its substantial equivalent which meets the requirements of MCLY:h.152 [:?,:• Yes _ No ❑ .• If you have c e ked v_s please indicate the type coverage by checking the aptar cpriate box. • ' A liability insurance pc:iay 0 . • O;her type of :ademnity 0 • - Bond 0 - •' • OWNERS INSURANCE WAIVER: I am aware that the rcensee dans rot have the insurance coverage requirec by• Chapter 152 of the Mass. General Laws, ana that my signature on th:s permit :cp.icaticn waves this requirement. . • • Check one: • Owner;— Agent 0 - ' Signature of Owner Cr Owners Agent ' • \SIGNATURE: BUILDING OFFICIAL APPROVAL: • • 7= _ . COMMONWEALTH OF MASSACHUSETTS - DEPARTMENT OF INDUSTRIAL ACCIDENTS . - 600 WASHINGTON STREET James Campoeu BOSTON, MASSACHUSETTS 02111 . Cpmm:ssoner WORKERS' CO SATION INSURANCE AFFIDAVIT • • I ikied/7 c47-91- (licensee/perminee) with a principal place of business/residence at: - 3O« t "4 s/ &t"&ió% HA - e1y' (Ciry/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. .l'i 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 _ 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 in which the homeowner also resides or on the grounds appurtenant thereto are not generally considered to be employers under the Workers' Compensation Act(CL C. 152,sect. 1(5)),application by a homeowner fora 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 Insunnce for coverage verification and that failure to Lure coverage as required under Section 25A'of MGL 152 can lead to the imposition 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.e. ,/ Signed this �� T day of ( Tl/1I 19 3 ii61414 %Perm cc' Licensor/Permit:or