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Home My WebLink AboutBLD-93-766 i 64"''44 o/� "07 /fJ ;j vr; v d TOWN OF YARMOUTH°e ' ibfr/Qr � MATTAC0Y0 Applic ion for a Permit to Build No. 76,6 40+w.uw�it UPON FINAL APPROVAL IZ-93 MAP PD LOT i- 9 7 FEE MUST ACCOMPANY THIS APPLICATION. DATE !erre/ 19 93 The undersigned hereby applies for a permit to build ./d9.,,� .3 according to the following speci ' ations 11. Name of property owner�9 e x- t pE R/CkSO 00 Tel.Yi.7-7. 57 Address 6 t,53---// 31- ,ff-eee_7 A%95X 2.Name of Architect(if any) Tel. 3. Name of builder mute( Address 4. License No. Tel. 5. Name of Mason address 6. License No. Tel. 7. Construction address a/ /In'e a-eov Acid 121 /d ema.7/ • Flood District 8. Date of subdivision Approval plain zone C1 Zoned 9. Private dwelling ❑ Estimated Cost DO NOT WRITE IN THIS SPACE Tpe of room No. 10. Multi family 0 ' /rot. o0 11. Commercial ❑ D2242e. " 5 CoKitchen 12. Other - �k4 100,1-Lt Oar Dining Rm. 13. No. of stories gn w< Living Rm. ie'. . .,. _ Bed Rm. 14. Foundation — Full 0 Half 0 Crawl 0 Slab 0 ""� " Bath 15. Materials — Wood 0 Cement 0 Other 0 cat/ Deck 16. Type of heat — Oil 0 Gas 0 Electric 0 Other 0 Closed porch 17. Garage — 1 0 2 0 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. . LOT RELEASED BY o-lignaturerte2fra o— PLANNING BOARD ----Address Flo As-Se// 57— Date firDate eve/Pe7 f7ASS-' 0 a/V 9 TOWN OF YARMOUTH BUILDING DEPARTMENT HOMEOWNER LICENSE EXEMPTION PLEASE PRINT: DATE �J �J ,, / �/ / , �B LOCATION ,2:/ l//j'e t�oQ D AFb,_, l/ e5TY/�,rmo e6'7i NUMBER ' STREET ADDRESS SECTION OF TOWN C—OMEOWNER" 4J4 , 46;ye- fQ,y (J7-317 7ay9 NAME HOME PHONE WORK PHONE C....--PlIESENT MAILING ADDRESS 021 "11.5 rr'/7 5:7- Es. T Es. eRej19-ss 011y9 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- MENTS� AND THAT HE/SHE WILL LY WITH SAID PROCEDURES AND REQUIREMENTS. !/ HOMEOWNER'S SIGNATURE a APPROVAL OF BUILDING OFFICIAL ,ry.„0a, , INSURANCE COVERAGE: I have a Ycues ent lability Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142. NoIf you have checked yes, 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. Ch ck one: - � �� - Owner, Agent ❑ Signa re •f • er cr Owners Agent ..:-- - COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF INDUSTRIAL ACCIDENTS W. 600 WASHINGTON STREET James.: Campoeu BOSTON, MASSACHUSETTS 02111 romm ss oner WORKERS' COMPENSATION INSURANCE AFFIDAVIT • C A � � I, .at _- SAN (licensee/permittee) • with a principal place of business/residence an • �� 4 /J7/55•!// 67 ,ev-eere 5S vol fl (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 XI am a sole proprietor and have no one working for kne. [ ) I am a sole proprietor, general contractor . . (circle one)and have hired the contractors listed below _ who have the following workers' compensation ansu ce policies: --"-•. •• -• ,. Name of Contractor . Insurance Company/Policy Number . - ,.. .. . • Name of Contractor • Insurance Company/Policy Number - • - Name of Contractor Insurance Company/Policy Number . . 9 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(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 iecure coverage as required under Section 25A'of MGL 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 5100.00 a day against me. d this e,_ „,„ 1.02- day of ir/ 4 O'T— , 19 93 License:!d' rmirec' LicensoriPermirtor • -^ 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,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: P>v/ / )/Mb '&J t(apeit.e l Est. Cost 15e22a0 C----Address of Work fin e- L/Odl� �d Sr j4/-I7jn277 Winer Name: ,04„, ott `Date of Permit Application: /OM/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 MOL • e, 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 U Owner Name