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Home My WebLink AboutBLD-93-780 ` - ; w .'% TOWN OF YARMOUTH °` ofroi 0 III' -y! eCk .t•°g' Application for a Permit to Build No. MO UPON FINAL APPROVAL P 161 4 -93 MAP 0 7 LOT D I 0 FEE MUST ACCOMPANY THIS APPLICATION. DATE /0//f 19 9-3 The undersigned hereby applies for a permit to build /003 acpording to the following specifications 1. Name of property owner R • � Bto Tel.3511 -40360 Address 57 du -"Wali. 2,NameofArchitect(if any) Tel. 3. Name of builder_ S Address 78 SW/hi At-e 4. License No. f\4/a 84'1 Tel. 34a - I zor 5. Name of Mason Address 6. License No. Tel. A v7. Construction address : i.. _ . `15 , oo. C .!strict 8. Date of subdivision Approval plain zone Zone 9. Private dwelling IEr Estimated Cost DO NOT WRITE IN THIS SPACE Type of room No. 10. Multi family 0 age(' 4 S� �e-pp.,R5 / (� 11. Commercial 0 .cpoilt4 - Esti 0/rir Kitchen 12. Other 0 Teo CD)E Dining Rm. 13. No. of stories 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 ❑ Family Am. Sun room 18. Swimming pool - Size Garage 19. Storage shed — Size Shed 20. Stove — Wood 0 Coal ❑ 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 // v 25. H.I.C.R. No. /05.7 7 , Z. LOT RELEASED BY Signatu PLANNING BOARD %ddress 7 ,S A Date ovf% ,Pet.nw/4,_14i- 1 .� _`_.. is COMMONWEALTH OF MASSACHUSETTS e....., __ 9 DEPARTMENT OF LNDUSTRIAL ACCIDENTS • .. - .., 600 WASHINGTON STREET - �ames Camvoe�+ BOSTON, MASSACHUSETTS 02111 • • Cor;m:ssconer WORKERS' COMPENSATION INSURANCE AFFIDAVIT • 1, Teo (licenseelperminee) . • with a principal place of business/residence at: • ' 7gS4 .fie Sy s L/4vvx�f, ( so,4G6e (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 [J I am a sole proprietor and have no one working for me. [64m a sole proprietor, general contractor or homeowner (circle one) and have hired the contractors listed below . - - . who have theefWorkers'orkers' compensation insurance policies: -• . . Name of Contractor . Insurance Company/Policy Number . Mt p ...,......L / ��,,,,,vt,,,, / G,,.,, ., Name of Contractor ., • .- Insurance Company/Policy Number . - 7.. - • • Name of Contractor Insurance Company/Policy Number - 0 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 fora 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 lnsurance for coverage verification and that failure to;mire coverage as required under Section 25A'of MGL 152 can lead to the imposition of criminal penalties • consisting of a fine of up to SI 500.00 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 L! day of C b2-e— , 194 3 —71,01/792.4 / _ is ' Licerse i Permute: .— il. Licensor/Permit:or TOWN dF YARMOUTH BUILDING DEPARTENT • . CONSTRUCTION SUPERVISOR FORM " ' PLEASE PRINT: • . JOB LOCATION: c) 7 C Q.._a_ I'Q✓y ^eS 0 ( J-+! w IA NUMBER e /, ' / / STREET. VILLAGE OWNER OF PROPERTY: ' ?nse tA-c' I.• F–UN.st.i11a -1 /, CONSTRUCTION SUPERVISOR: - /Cow (Li41g . D../... c�C/Y—/� ' • - NAME / .. LICENSE NO. PHONE NO. . • •• ADDRESS: t� ., i i. i / /• K Q YN'°d�'�t , . . • • .. 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 COCLMONWEALTH, 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 THAT 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:AMT. • I HAVE READ AND UNDERSTAND MY RESPONSIBILITIES UNDER THE RULES AND REGULATIONS ,FOR LICENSING CC'I• STRUCTION SUPERVISORS IN ACCORDANCE ,LITH 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: • . • . I have a current ility insurance petit/or Ps substantial equivalent which meets the requirements of of MCL th.152 :'-.', " ' . '. . No ❑ If you have checked v_s, p'eerseeiindicate the type c average by checking the ap;:cpriatebox: . ., �: '" A liability insurance pciicytd' Other type of ademndy 0 •• • - Bond 0 • - • • OWNER'S INSURANCE WAIVER:I am aware that the licensee dcei rot have the insurance coverage required.`_y Chapter152 of the Mass: General Laws. ana that my signature on tn:s permit a:p.ic:tion waives this requirement• Check one: •• , OwnerO Agent 0 ' • 54nature or Owner or Owner s+ en ' • SIGNATU• • 9 , • BUILDING OFFICIAL APPROVAL: ". 1 ` • • Suggested Affidavit for Home Improvement Contractor Permit Application For Orrice Use Only NAME OF CITY/TOWN Permit No, Date AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application MGL e.142A requires that the"reconstruction,alteration.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 building"be done by registered contractors,with certain exceptions,along with other • requirements. Pea—, Type of Work: P 0 Est. Cost 2900 Address of Work 57'/` ? o (-Al 05 Owner Name: R, et"...•,/,•6 Date of Permit Application: /0 / 3 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 agent ofthe owner: � ^ —O y l(14../4/� /05-179 Datfata— 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