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Home My WebLink AboutBLD-93-773 I- pvirdli t_ are-/44 ;'. `_ , i,, c` TOWN OF YARMOUTH • TTAGM4� cck..... "[[5 0,, Application for a Permit to Build No. 773 IRb- UPON FINAL APPROVAL \k-k. MAP Si LOT /3 7 4q FEE MUST ACCOMPANY THIS APPLICATION. DATE � V 19 93 The undersigned hereby applies for a permit to build /0//,93 according to the following specifications 1. Name of property owner /4's L2,//b . !/ I/ / Tel. Address 30 G�ea r/0 v'cio �d . iS f� 2.NameofArchitect(i / � r... /„' f Tel. a Name of builder �e AIL= l if �✓_ ddress W 7 t ,tr t 4. License No. /0 Aro Tel. o-�3 O`l�7 s`"""�'O k caret 5. Name of Mason Address 6. License No. T , / 7. Construction address c30 C u✓thud ,ep/ (0 • y . Flood District �_,/� 8. Date of subdivision Approval plain zone G- Zone 7" 9. Private dwelling 0 :timated Cost DO NOT WRITE IN THIS SPACE _ 10. Multi family 0 J6a/- °veil - Type of room No. 11. Commercial 0 voz, a.,r r 1/E�rT T6 Cv�r e p l y e,� - Kitchen 12. Other ❑ et I I K L_ w Dining Rm. 13. No. of stories rr ,3 ?'S` Crz7 Living Rm. �r k, �r 2+� 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 — 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 of li -ide line 25. H.I.C.R. No. LOT RELEASED BY Signature ., `-r PLANNING BOARD Address til Date O2rG3 TOWN OF YARMOUTH ^ BUILDING DEPARTMENT HOMEOWNER LICENSE EXEMPTION PLEASE PRINT: DATE �( �v/9? JOB LOCATION Y Ired a r/t/ Circ NUMBER STREET ADDRESS SECTION OF TOWN "HOMEOWNER" / /�S 4/A NAME HOME PHONE WORK PHONE PRESENT MAILING ADDRESS , 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 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 COMPLY WITH SAID PROCEDURES AND REQUIREMENTS. HOMEOWNER'S SIGNATURE APPROVAL OF BUILDING OFFICIAL INSURANCE COVERAGE: I have ayes currnt liability Ino Once policy or Its substantial equivalent which meets the requirements of MGL Ch. 142. If you have checked yes, please indicate the type coverage by checking the appropriate box. r C/l A liability Insurance policy 1 — Other type of Indemnity 0 Bond 0 a f OWNER'S INS •AN EWA ERM am aware that the licensee d s of have the insurance coverage required by Chapt-� 4 • the /ass. 1e Laws, and t n r s permit application waives this requirement. /.aLL� e't Check one: OwnerA 0 Agent ❑ Signa ure of • r or Owners A. nt t ..- .... .. COMMONWEALTH MONWEALTH OF MASSACHUSETTS vo., __?...r. DEPARTMENT OF INDUSTRIAL ACCIDENTS - -- V7 600 WASHINGTON STREET James J Camppeu BOSTON, MASSACHUSEi is 02111 • Comn:ss oner WORKERS' COMPENSATION INSURANCE AFFIDAVIT • I, HeL / lea//a5)e✓ (Iicensee/perminee) • with a principal place of business/residence at Y/ 77-11h4)r eve/ Sett lt:opi r/ o01-r (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 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: ------ r• 7,- - • _1t Name of Contractor . - . . Insurance Company/Policy Number.. . ._- ., . Name of Contractor - Insurance Company/Policy Number • - - • Name of Contractor Insurance Company/Policy Number - • 0 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 iecure coverage as required under Section 25A'of MGL 152 can lead to the imposition of criminal penalties • consisting of a fine of up to $1500.00 and/or imprisonment • up to one year and civil penalties in the form of a Stop Work Order and a fine o(5100.00 a day against in / Signed this day of /O/Y , 19 ( 3 Licensee:Perminet' LicensoriPerminor • t • Suggested Affidavit for Home Improvement Contractor Permit Application • For Office Use Only i / 4/ NA1'ff OF CITY/TOWN Permit No. Jl/✓W1dµ'j' Date AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application MGL c.142A requires that the"reconstruction,alters lion.renovation,repair,modernization.conversion,inprovement,removal.demolition. or construction of an addition to any pre-existing owner-occupied budding containing at least one but not more than four dwelling units....or to structures which are adjacent to such residence or pudding"be done by registered contractors,with certain exceptions,along with other requirements. / /' / �J Type of Work: �C✓vne Ott/e/ / -CAIS? // Val c- Est. Cost �I�/JW, Address of Work 30 C4vheivi f� jar. pu�� / !a • Owner Name: / f!( D1//1L '//// Date of Permit Application: /9/03 I hereby certify that: Registration is not required for the following reason(s): • _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. 142A. Signed under penalties of perjury: I hereby apply for a permit as the a ent f t filer: 03 /71 411 A,PO? 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