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Home My WebLink AboutBLD-93-768 E °' . q� TOWNOFYARMOUTH si L+:n 5G Application for a Permit to Build No. TO, CO UPON FINAL APPROVAL \ D'�3' MAP 7,5--- LOT/ w /Z1 FEE MUST ACCOMPANY THIS APPLICATION. DATE )0A 2- 19 73 The undersigned hereby applies for a permit to build ///.x/93 according to the following specifications /i4/ -�' �` '�j-3 1. Name of property owner R64.e, g eq jqv Tel. Address 3`I 0 -(4<n 490-14 s, y../...1 . 2.Name of Architect(if any) Tel. 3. Name of builder Unit Y40/1;404 _Address 45 n-c[tj At ✓3 S. Y✓M. 4. License No. 031 10 Z- Tel. Sag- 348 - t7 tet 5. Name of Mason Address 6. License No. Tel. II 7. Construction address 3 `f IA) d i t/S p4 3-f 3. Yo✓ FloodDistrict 8. Date of subdivision Approval plain zone C-r_ Zone R `/b / 9. Private dwelling (Ff Estimated Cost DOW -_( Tyke of room No.EJN THIS SPACE 10. Multi family 0 2i oo .00 grA l pI 11. Commercial 0 V cN t -s tr: n A d 7 �S cue, Kitche 12. Other i- ❑+0„cock (� I �— Dining Rm . c- 13. No. of stories one ` e R°° 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 0 2 0 Family Rm. Sun room 18. Swimming pool - Size Garage 19. Storage shed — SizeShed 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. 111 (+1} g LOT RELEASED BY Signature -Pe--176 /• li?i .--- PLANNING BOARD Address L P Pt e(L) We la St Y4✓"k. fV, Date TOWN OF YARMOUTH • BUILDING DEPARTMENT CONSTRUCTION SUPERVISOR FORM ' • PLEASE PRINT: ' ' ' // ' • JOB LOCATION: .3 e�4�<� S pc f 5 , y✓ivt , NUMBER STREETVILLAGE ' OWNER OF PROPERTY: ' ROL,. ' .. 5 eq wt a v sob CONSTRUCTION SUPERVISOR: pole/1-- oft:roy 3y 4 -2$2y NAME• LICENSE NO. PHONE NO. ADDRESS: Q M et L/ lI(d 4. .. ' ' g ':' : Yee fot..; 44 4 , • LICENSED DESIGNEE: 03 y 9.0 Z (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 ELMENTS OF BUILDING AND STRUCTURES ONLY PURSUANT TO THE STATE BUILDING CODE AND ALL OTHER APPLICABLE LAWS OF THE • COMMONWEALTH, 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 DE4OLITION AS REGULATED BY SECTION 109.1.2 OF THE CODE AND THESE RULES AND REGULATIONS. IN THE EVENT THAT SUCH LICENSEEE IS NO LONGER SUPERVISING SAID PERSONS, THE WORK SHALL IMMEDIATELY CEASE UNTIL A SUCCESSOR LICENSE HOLDER IS SUBSIITUTED . ' ON THE RECORDS OF THE BUILDING DEPARDCNT. ' ' ' ' ' I HAVE READ AND UNDERSTAND MY RESPONSIBILITIES UNDER THE RULES AND REGULATIONS ,FOR LICENSING CC:L- STRUCTION SUPERVISORS IN ACCORDANCE WITH SECTION 109.1.1 OF THE STATE BUILDING CODE. I UNDERSTA-N: THE CONSTRUCTION INSPECTION PROCEDURES AND THE SPECIFIC INSPECTION AS CALLED FOR BY THE BUILDING OFFICIAL. . . . INSURANCE COVERAGE: • ... I have a current liab'' Y insurance peticy or its substantial equivalent which meets the require.•nents of MGLth.152 '..:'e,:- - . Yes : NoC3 , .. .. ... .. .. . _ _- If you have checked v_s, please indicate the type coverage by checking the ap:rcpriate bcx ; A liability insurance pc cy 22. C'ier type of :idemnity 0 • Bond 0 - - • • • • . OWNER'S INSURANCE WAIVER:I am aware that the r:censee deet' rot have the insurance coverage required•`_y C.`.apter 152 of the Mass. General L^•,vs, aria Mat my signature on th:s permit :ep:icaticn wives this requirement • • Check one: • OwnerD Agent 0 • S:gr.aeure atOOwwner Cl Owners Agent ' SIGNATURE: I •% % =,a_,�— BUILDING OFFICIAL APPROVAL: — — --- —wawa IP e m_ . COMM() . V ,. TH OF MASSACHUSETTS ti ' .' DEPAR" . 'T•OF INDUSTRIALACCIDENTS ...v . . ,-;;r--11'. 6 n WASHINGTON STREET James CamDbeL BOSTON, MASSACHUSETTS 02111 coni ssroner pp II /"�WORKERS'kkENSATION INSURANCE AFFIDAVIT • • 1, i\nL�ei4 or✓': S ✓l (licensee/permittee) with a principal place of business/residence an • I ____9_1....._L e:l� ;�[� , s. Y4,, � (xt4 02 eCe (City/State/Zip) do hereby certify, under the pains and penalties ofperjury, that: . [ ] I am an employer providing the following workers' compensation coverage for my employees working on this job. Insurance Company Policy Number 1 am a sole proprietor and have no•one working for me. [ ) I am a sole proprietor, general contractor or homeowner (cirde one) and have hired the contractors listed below - . who have the following workers' compensation insurance policies: •• . z- • -• Name of Contractor . '. Insurance Company/Policy Number .. . ._.... . Name of Contractor - Insurance Company/Policy Number • - - - Name of Contractor Insurance Company/Policy Number - [] 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 An(CL 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 cagy of this statement will be forwarded to the Department of Industrial Accidents'Office of Insurance for coverage verification and that failure to;ecure coverage as required under Section 25A'of MGL 152 can lead to the imposition of criminal penalties • ,r 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. j� r- r C Signed this 12 T I day of 8G Tob t✓' , 19 / 3 LicensoriPermirtor *a' - i • fps Suggested Affidavit for Home Improv- ent Contractor Permit Application For Orrice use Only NAME OF CITY/TOWN Permit No. - - u Date AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application MGL c.142A requires that the"reconstructio .alteration.renovation.repair,modernization.conversion,inprovement,removal.demolition, or construction of an addition to any pre-e iistingowner-recuored building containingat 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. • Type of Work: --.5 ?e — Roo c- Est. Cost1z 400 t oo fi, 6 t ,r �p Address of Work I/r u , L<.r S RS. Ytv'iryowe-ffi At Owner Name: 'di ,N t S c 9 *t QA Date of Permit Application: Oo-E" 1Z+'i )913 J , + 1 I hereby certify that: Registration is not required for the following reason(s): • art .•, _Work excluded by law _Job under$1,000 _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. I42A. Signed under penalties of perjury: I hereby apply for a permit as the agent of the owner: 'r °IVO 4RCocei{- ho ft ;So✓l / T g 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