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Home My WebLink AboutBLD-93-769 Aii., t� ; ol TOWN OF YARMOUTH ° Kfret) °/1f13 MATTAC E S K <aan. "/ Application fora Permit to Build No. 749 ;,,, JO,-, 3 '13 . z UPON FINAL APPROVAL ✓ MAF c& D LOTe V9 A FEE MUST ACCOMPANY THIS APPLICATION. DATE !% g 13 The undersigned hereby applies for a permit to build , y. /0//3/73 acco�r ing to the following specifications ///3 7a �: PLOT PLAN . FOR LOT if P 1 Pt ' 4 Indicate location of garage or accessory building Additions with dashed lines Sewerage disposal (cesspool) ® • , Well /21 I • � I (lot /08r ft. rear) I - — Al�ttor'sI ` t Abutt Nate P(64.111-4Name Lot # li t f-- ms° -- 1 • Lot if A 7it% _$XI'o i 5 � REAR YARD _ -- - - If tl If t • a I • I $'tCi • corn lot, 17 . .ft. I cone write in name • writ of stet. I • � name w • othe 0 I 0 stree 0K SIDE YARD SIDE aYk • HOUSE 0-- -1.1 FT 0 ' • 0 __ FLT -Cr • • I • I • •\ SET BACK ' H I 1 • (lot eV ft. frontage) .. \ / awKear,uuAwKv r DQlvs \ / \ / (NAME OF STREET) • . . / \\ -Information CAR(301�C= / \ Supplied by `\ �" 4 — / TOWN OF YARMOUTH • BUILDING DEPARTMENT . CONSTRUCTION SUPERVISOR FORM PLEASE PRINT: ' • JOB LOCATION: g • l'/./fllc, Ar,r, ll'imur DCL sl'..y. koo F-/ • , NUMBER STREET . . ! . VILLAGE • .OWNER OF PROPERTY: ' A'?- !%'='r7.77 , A ( r:' 7 r?!7,C/-a . • CONSTRUCTION SUPERVISOR: . I M$S .� ; I' '&Mv7 " . /09377 760- ° . NAMEICENSE NO. . PHOENNO. • ADDRESS: ' . rC "S7� -0 •• Co ' �. 1NJISPI � ' 0- � �v • �E + • LICENSED DESIGNEE: • (IF OTHER.THAN SUPERVISOR) NAME , s . • 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 ' 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 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.. 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 DEPART ENT. ' • I HAVE READ. AND UNDERSTAND MY RESPONSIBILITIES UNDER THE RULES AND REGULATIONS ,FOR LICENSING CCN- STRUCTION SUPERVISORS IN ACCORDANCE WITH SECTION 109.1.1 OF THE STATE BUILDI\G CODE. I UNDERSTAN: ' THE CONSTRUCTION INSPECTION PROCEDURES AND THE SPECIFIC INSPECTION AS CALLED FOR BY THE BUILDING OFFICIAL. . . INSURANCE COVERAGE: : . .• . . .,'• tip I have a cure lab:lity insurance policy or its substantial equivalent which meets the requre:nents at MGL'Ch.152_ - Yes No ❑ ;, . If you have checked Is please indicate the type caverns by checking the upa cpriate box. -_ y ` A liability insurance pc:;CyX Other type of :.idemnity❑ Bond 0 -• -1-:••• '-• - O'NN 'S I SURANCE WAIVER:I am aware th the t censee deer ret have the insurance coverage required by • ' Chap'-r15^ f the Mass. General Laws. a • tha `� igr:a:ure on mit.permit ccpiles:ion waves this requirement —ir i Ca ' /, • Check one: ••p/ 1 S;gna'IR7''.alisvt . Owner° Agent k rcr O..nersAgent SIGNATUR '` if MEd g[7ILDING OFFICIAL APPROVAL: TOWN OF YARMOUTH BUILDING DEPARTMENT HOMEOWNER LICENSE EXEMPTION PLEASE PRINT: > DATE Af//�/?,pp� ,/ , JOB LOCATION ( go fn(ukftgnacaJ/Cu7' .Q so. Y /�-(oilv}f r/�NUMBER //�� STREET ADDRESS II + SECTION OF TOWN "HOMEOWNER" ER 114 . CA-no,ue 348 -86`7 . `� NAME HOME PHONE WORK PHONE . PRESENT MAILING ADDRESS d Alog4gNAwgar D(L, Sa. , Hou7N MA 02660 CIT .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 ATTACHE D 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 MPLY WITII S PROCEDURES AND REQUIREMENTS. HOMEOWNER'S SIGNATURE �tog,�/ A .6�...ra ` APPROVAL OF BUILDING OFFICIAL INSURANCE COVERAGE: I have a Ycurt es liability InsuNorance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142. If you have cher ,des, please Indicate the type coverage by checking the appropriate box. • A liability insurance policy ix Other type of Indemnity 0 Bond 0 OWN--. INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chat 2 of the •-s s, General ws, t my signature on this permit application waives this requirement. AO // Check ane: Owner ❑ Agent sir eofOwner orOwner sA en - COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OFINDUSTRIAL ACCIDENTS •S7 600 WASHINGTON STREET • James J Camvoeu BOSTON, MASSACHUSETTS 02111 comm:ss over WORKERS' COMPENSATION INSURANCE AFFIDAVIT • I. I idE 77 61-- (lice sec/permiaee) • with a principal place of business/residence at flab G12 7' W£SGield A, c Dmfs (City/State/Zip) do hereby certify, under the pains and penalties of perjury,that: I am an employer pioviding the following workers' compensation coverage for my employees working on this job. STA/A- CP-336g65—g C4-14 Insurance Company Policy Number ( ] I am a sole proprietor and have no one working for me. ( ] 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 .. .. Q 1 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 Insurance for coverage ' verification and that failure to secure 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. Signed this _ day of OCT 7 / , 19 Qs 1176:44a.id License / rrr:::-e: Licenso :Permizttr • Suggested Affidavit for Home Improvement Contractor Permit Application For orrice Use Only NAME OF CITY/TOWN Permit No. • Dale 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-misting 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 ecceptions,along with other requirements, Type of Work: Can 72/X e r s��6 Est. Cost /000 Address of Work ff0 Pi4/,(Jeite /�4�1UvtV T De. Owner Name: Eelossr /�,/Y'.cn'�D Date of Permit Application: /0 —&r 7 3 I hereby certify that: Registration is not required for the following reason(s): Work excluded by law Job under 51,000" i ' 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 the agent of the owner: /o/ /g 3 AA /0937V Date Contractor Name Registration No. OR: • Notwithstanding the above n e, I hereby apply fo� as the owner of the above property: D t Owner Name