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HomeMy WebLinkAboutBLD-93-782 . —7-, TOWN OF YARMOUTH iokiffi ' ,,,"< ..�'g Application for a Permit to Build No. /kV_ UPON FINAL APPROVAL r ) MAP ‘F LOT 1 S. FEE MUST ACCOMPANY THIS APPLICATION. DATE /o//5 19 93 The undersigned hereby applies for a permit to build according to the following specifications 1. Name of property owner ill -� CO2---14 r c Ac Tel. Address s' e.,, i 211c oq/ ,e• 2.Name ofArchitect(ifany) I Tel. 3. Name of builder Mt n tfiriL't9 1fi x9-1)4 j Address 4 gal-0 , O. rt."0415 . 4. License No. ©G'a7.cS Tel. r7��42,5? 1 5. Name of Mason Address 6. License No. Tel. _, II,e)coic> 7. Construction address /4 Ctir 1,e sit Cc, ?If 24- ci• x(42 ak. o 0-141 Flood / District 8. Date of subdivision Approval plain zone Zone 9. Private dwelling 0 Estimated Cost DO NOT WRITE IN THIS SPACE Type of room No. � 10. Multi family ❑ 2o Raptyt25 / 11. Commercial ❑ ' 7- e , �' '''° Kitchen 12. Other 0 fi , n'`c"ft lie. 01 >> 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 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 I ine Side line 25. H.LC.R. No. 102- 18� d.__—c, LOT RELEASED BY Signature �`"'I i-PLANNING BOARD Address 4//¢^n�2). � C /te 0 � t • Date Ill DG I3 - _ TOWN OF YARMOUTH BUILDING DEPART:D:NT . -,t CONSTRUCTION SUPERVISOR FORM ) PLEASE PRINT: • {{ �Q`AA°.ir/ . JOB LOCATION: 1 e4 �� v� Q� c - • NUMBER ;pt.-C STREET VILA E ' OWNER OF PROPERTY: ' " .r Q Cfl(C 1\ CONSTRUCTION SUPERVISOR: • • •l• . • -/tI s • •.- Z Z. NAME . LICENSE NO. PHONE N0. ADDRESS: _ 4 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 ' 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 DE1OLITION 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 L'NEDIATELY CEASE UNTIL A SUCCESSOR LICE`ISE HOLDER IS S'uBSTITUTED • ON THE RECORDS OF THE BUILDING DEPARTF.ENT. ' • l ' ' ' : ': .. • I HAVE READ AND UNDERSTAND MY RESPONSIBILITIES UNDER THE RULES AND REGULATIONS ,FOR LICENSING CC:1- STRUCTION SUPERVISORS IN ACCORDANCE WITH SECTION 109.1.1 OF THE STATE BUILDING CODE. I UNDERST2tN: THE CONSTRUCTION INSPECTION PROCEDURES AND THE SPECIFIC INSPECTION AS CALLED FOR BY THE BUILDING OFFICIAL. INSURANCE COVERAGE: , I have a current liability insurance policy or is substantial equivalent which meets the requirements of MGLth.152 :.'.•" ' . Yes - c If you have checked v_s, please indicate the type coverage by checking the apprcpriate box. " - ' -.` A liability insurance pc:icy Other type of :.idemnity 0 Bond 0 • • -- .. 7 : OWNER'S INSUAANC_WAIVER:I am aware that the licensee does not have the insurance coverage required.bv C`apter 152 of the Mass: General L^ws, ana that my signature on ms permit :aplica:ion wanes this requirement . • Check one: • Owner A t • SIgnaturs of Owner or O/rcaner:Agent gen ❑ SIGNATURE: / / /I A. BUILDING OFFICIAL APPROVAL: • Suggested Affidavit for Home Improvement Contractor Permit Application For Cace Use Only NAME OF CITY/TOWN • Permit No. Date A11'ILAVIT Home Improvement Contractor Law • Supplement to Permit Application MGL e.142A requires that the"reconstruction,alteration,renovation•repair,modernization.conversion.inprovement,removal,demolition, or cnnstniction of an addition to any pre-existing owner-occupied huilding containing at least one hut not more than tour 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: le. Rot> Est. cost 2 e-o Address of Work l Ii ?e do Owner Name: Ye core 44 / c fir Date of Permit Application: 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 asasthe agent of the owner: qqq le 7 g 7 �4 044 q2 441 L /rile / Date Contractor Name J Registration No. OR: • Notwithstanding the above notice, I hereby apply for a permit as the owner of the above property: Date Owner Name • • • • • • • • • • In accordance with the provisions of MGL c 40, S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 111, S • 150A. The debris will be disposed of in: - • VP9-2 CiJ L ✓� p, // (Location oFaci i F ltry) • • • • /1��� Signature of Permit Applicant Date a . ' '3.S.-— COMMONWEALTH OF MASSACHUSETTS p' ,__- c b C• 94-:_ 74•4' . . DEPARTMENT OF INDUSTRIAL ACCIDENTS - _. ._ . - -. • 60O WASHINGTON STREET Dames Gamooeu BOSTON, MASSACHUSETTS 02111 . • Cor;m:ss/oner WORKERS' COMPENSATION INSURANCE AFFIDAVIT • • ,, ft , „ ,/ 4 1-1,..14d _ (licensee/permittee) • • with a principal place of business/residence at (City/Sure/Zip) . do hereby terrify, 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. [ j 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: :•• -=-M -. - •-- ,.- . . Name of Contractor - Insurance Company/Policy Number . • .... - Name of Contractor Insurance Company/Policy Number • - . Name of Contractor Insurance Company/Policy Number . . Q 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 Insurance for coverage verification and that failure to secure coverage as required under Section 25A'of MGL 152 can lead to the imposition of criminal penalties ' consisting of a fine of up to 31500.00 and/or imprisonment of up to one year and civil penalties in the form of a Stop Work Order and a fine of$100.00 a day against me. Signed this 6v-h/` day of CZ-4t4 , 19 ' x.y...dr Licen.seeiPermirec' LicensoriPermirtor,, .sinr•i: ter 1.•