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Home My WebLink AboutBLD-93-763 4 - fl/P9//43 4t� , +moo TOWN OF YARMOUTH a e /a/1/g3 t C'; e 0 . - y; tot -MATTAC�E $ a` ��(J v 4....,•S6cg,- Application for a Permit to Build No. pow� /8 42--13 fi 14,_ a - -- A Salt, l ,Z , UPON FINAL APPROVAL MAP el-Sr LOT T FEE MUST ACCOMPANY THIS APPLICATION. DATE 5ep1 e 3 19 S S The undersigned hereby applies for a permit to build /e//g93 according to the following specificationsAy/A -193 1. Name of property owner I )-% P- s b - n w f k_c Tel.3`+ If - IV-1,1 Address 1,3 0c- 4- Ave S.. Y4'mo..* 2.Name of Architect(if any) Tel. 3. Name of builder 0 w A e r Address 4. License No. _ Tel. • 5. Name of Mason Address 6. License No. Tel. 7. Construction address 4 3 O c-e c.. Ave l 4. Y, FloodDistrict p 8. Date of subdivisionApproval plain zone Q 9 ie./0,A Zone 1%. ` 9. Private dwelling G7/ Estimated Cost R.11-513 DO NOT WRITE IN THIS SPACE 10. Multi family 0 ¢o .1 CD. � �a ' �'°¢/�' �J° ,Ty Type of room lNo. 925 ylk ,w,✓R7/0ks 11. Commercial 0 � L if Kitchen 12. Other ❑ �a ,A E35:0— Dining Rm. �� _ ,, Living Rm. 13. No. of stories I I ` - J Bed Rm. 14. Foundation — Full R Half 0`Cr wl d Slab' % , /0 dery P Bath 15. Materials — Wood DCemen Other 0 t/0 7, oil edt, Deck 16. Type of heat — Oil 0 Gas Q Electric N Other ❑ Closed porch Family Rm. 17. Garage — 1 ❑ 2 ❑ Sun room 18. Swimming pool - Size Garage 19. Storage shed — Size / - Shed 20. Stove — Wood IiCoal pe Alterations 2 21. Size of lot: No. of feet front / i o No. of feet rear I a S No. of feet deep la 22. Size of building. No. of feet front Co 1-(. ' No. of feet side' s 1 .Lisa No. of feet rear C Y. — 23. Distance from nearest building: Front\C-18-:Ni Ft. side Ft. side Rear 24. Distance back from line or street ff ' From rear lot line 33 / Side line is * 1 -L- 25. H.I.C.R. No. LOT RELEASED BY Signature Ci . n i • (/N ••• /i �iI c PLANNING BOARD Address C. 3 0 c c s- A .. Date S o. ya.n.o .Jg A 4 J I p2Cec/ ' 9/ziy3 rr • C F r L _ 4PPLICANT: 7i�O I)J}2 $ /0. biIIG�T BUILDING PERMIT D: ADDRESS: 6 :3 5:y! TELE. NO. : ,�7-5/./4(75e- DATE FILED: BLDG. SITE LOCATION: Sffl:07,1/� MAP//: 0.14' LOU: THE FOLLOWING INFORMATION OUTLINES THE PROCEDURAL STEPS REQUIRED TO OBTAIN A PERMIT TO BUILD, ALTER, OR ADD TO A STRUCTURE WITHIN THE TOWN OF YARMOUTH. THE BUILDING DEPARTMENT WILL DETER- MINE COMPLIANCE TO THE FOLLOWING (A) ZONING REQUIREMENTS (B) HISTORICAL DISTRICTS -(C) FLOOD PLAINS ZONING. THE BUILDING DEPARTMENT WILL BE RESPONSIBLE FOR ASSISTING THE APPLICANT THOUGH THE FOLLOWING DEPARTMENTS: RESIDENTIAL AND/OR COMMERCIAL BUILDING WATER DEPARTMENT: DETERMINES COMPLIANCE OF WATER AVAILABILITY. ENGINEERING DEPARTMENT: DETERMINES COMPLIANCE FOR PARKING AND DRAINAGE. CONSERVATION COMMISSION: DETERMINES COMPLIANCE TO WETLANDS ACTS, I.E. : IF LOT(S) BORDER ANY TYPE OF WETLANDS, STREAMS, PONDS, RIVERS, OCEANS, BOGS, BAYS, MARSH LAND, ETC. HEALTH DEPARTMENT: DETERMINES COMPLIANCE TO STATE AND TOWN REGULATIONS, I.E. : REQUIRE- MENTS FOR SEPTAGE DISPOSAL AND OTHER PUBLIC HEALTH ACTIVITIES. FIRE DEPARTMENT: DETERMINES COMPLIANCE TO STATE AND TOWN REQUIREMENTS FOR PERSONAL SAFETY, PROPERTY PROTECTION, I.E. , SMOKE DETECTORS, SPRINKLER SYSTEMS, • ETC. THE FOLLOWING DEPARTMENTS MUST SIGN OFF, IN THE RESPECTIVE ORDER, PRIOR TO BUILDING INSPECTOR ISSUING THE REQUIRED BUILDING PERMIT: REVIEWED BY: 1. WATER DEPARTMENT DATE: N/A: 2. ENGINEERING DEPARTMENT: DATE: N/A: 3. CONSERVATION: DATE: N/A: 4. HEALTH DEPARTMENT DATE: N/A: /� INDUSTRIAL AND/OR COMMERCIAL PERMITS 5. WIRING INSPECTOR: / �e DATE: // Q/-c'.3 N/A: 6. PLUMBING INSPECTO { ( t . .[ `` 4 4 t DATE/L / - y3 N/A: 7. FIRE DEPARTMENT:/- DATE: N/A: • PLEASE NOTE ALL STUMPS AND/OR BRUSH MUST BE DISPOSED OF AT AN APPROVED SITE. A SIGNED RECEIPT FROM THE DISPOSAL SITE MUST BE SUBMITTED TO THE BUILDING DEPARTMENT PRIOR TO ISSUANCE OF THE BUILDING PERMIT. COMMENTS: 615 �l_gu�s.S r�o7i7<a�/�ri�i-7 f �iyftz�r'7�i or • BL:4/89 TOWN OF YARMOUTH le . - BUILDING DEPARTMENT . . ' CONSTRUCTION SUPERVISOR FORM PLEASE PRINT: ' JOB LOCATION: (0 e? - OCE<'t' lie . Sin LifQ/,.>,•G1- , NUbtBER/ STREET VILLAGE - . OWNER OF PROPERTY: - r - 1 KO /)..4.1 - L i .e„ r 3 t/A-4 CONSTRUCTION SUPERVISOR: - ' NAME . . LICENSE NO. . PHONE NO. ADDRESS: • ' 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 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 - COMPMONWEALTH, 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, REMOVAL OF DEMOLITION 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 IIDLEDIATELY 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 LICENSING CCL. 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: •.. • - mGL ;: I have a current liability insurance pclicy or its substantial equivalent which meets the requireents of M10h.152 • Yes _ ;, No ❑ If you have checked v`s, please indicte the type c;verage by checking the ap:rcpriate Incr.. :—.:::`'. : - - -". A liability insurance pc:icy 0 0:her type of indemnity 0 .. • Bond 0 -•-•• -- • - •• . OWNER'S INSURANCE WAIVER:1 am aware that the ccensee dces ret have the insurance coverge require:rt Chapter///YTT555..222 of the Mass. General s. ana that my sig-azure cn tr s permit :::.ica:icn waives this re:akaren_ / / / r C ck one: 0 ( r ews, 4. vl r . Owner' Agent❑ S:gnawre of C.ner or Owner s Agent ti SIGNATURE: • BUILDING OFFICIAL APPROVAL: • COMMONWEALTH OF MASSACHUSETTS . DEPARTMENT MENT OF INDUSTRIAL ACCIDENTS S' 600 WASHINGTON STREET James Campoei, BOSTON, MASSACHUSETTS 02111 ror..m,sstonet WORKERS' COMPENSATION INSURANCE AFFIDAVIT • 4 • ,...• rtier (—) • 1-8QACC (I iccnsce/permittee) • with a principal place of business/residence an. �S CC-C,-- ,fue• S ya'en. pa-C (9 (City/Sate/Zip) do hereby certify, under the pains and penalties of perjury, that: (1 1 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. • [ ) 1 am a sole proprietor, general contractor or aril(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 - Id 1 am a homeowner performing all the work myself. NOTE:.Pleasc 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 whist 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 recuired 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 aai4 inst me. / Signed this 1 AoAH 72vs/. /3 day of S'c'ale- , 19 5' _ Licer.sceiPermit:ct: LicensoriPermirror Suggested Affidavit for Home Improvement Contractor Permit Application • For Office Use Only NAME OF-CITY/TOWN Permit No. t_ G,/rn a v+i_. Date v) AFFIDAVIT Home Improvement Contractor Law - Supplement to Permit Application MGL c.142A requires that the"reconstruction.alteration.renovation.renair.modernisation.conversion,inprovement,removal.demolition. or construction of an addition toanv preccisting owneroccunied budding containing at least one but not more than four dwelling units....or to structures which are adiacent to such residence or building"be done by registered contractors,with certain exceptions,along with other requirements. 1 1 ' 1 repILcc win¢�C oyyf Wy �l / Siell reac.lo tu.le, Type of Work: Full �J ;c•s Lis 1'c&c eio.i .ct(a/fict. v4:t ,t ' 0- Tice Cost Sao Address of Work CJS Q ccc� mac f y Owner Name: ! O n.es J/kg • • Date of Permit Application: I`( /?/ 53 1 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. 1d2A- 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 ti c, I hereby apply for a permit as the owner of the above property: Date Owner Name