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APPLICANT: lAk/Uo,,4y17 /3c . ca, BUILDING PERMIT 0: � J
ADDRESS: Zo HA Arnt/J , So 7J(QV1VLV ' TELE. NO. : 371- 229 3 DATE FILED:- •
BLDG. SITE LO'L"nTION:36 C-lmaeL lOIN/7 N M% MAN: 4 L011: (Z 5
THE FOLLOWING INFORMATION OUTLINES THE PROCEDURAL STEPS REQUIRED TO OBTAIN A PERMIT TO BUILD,
ALTER, OR ADD TO A STRUCTURE WITHIN THE TOWN OF YARMOUTH. THE BUILDING DEPARTMENT WILL DETER-
MINE• COMPLIANCE TO THE FOLLOWING (A) ZONING REQUIREMENTS (B) HISTORICAL DISTRICTS (C) FLOOD
PLAINS ZONING. THE BUILDING DEPARTMENT WILL BE RESPONSIBLE FOR ASSISTING THE APPLICANT THOUGH
THE FOLLOWING DEPARTMENTS: ,
RESIDENTIAL, AND/OR COMERCIAL BUILDING
s \ -
WATER DEPARTMENT: DETERiINESJCOMP 'IANCE OF WATER AVAILABILITY. ,•
ENGINEERING DEPARTMENT: DETERMINES-COMPLIANCE FOR PARKING AND DRAINAGE.
CONSERVATION COMMISSION: DETER}TNES\COkPLIANCE TO WETLANDS ACTS, I.E.: IF LOT(S) BORDER ANY
\ (TYPE OF WETLANDS, STREAMS, PONDS, RIVERS, OCEANS, BOGS, BAYS, MARSH
SAMA, ETC. , ..
HEALTH DEPARTMENT: • DETPRMINES COMPLIANCE TO STATE AND TOWN REGULATIONS, I.E. : REQUIRE-
MENTS FOR SEPTAGE DISPOSAL AND OTHER PUBLIC HEALTH ACTIVITIES.
FIRE DEPARTMENT: DETERMINES COMPLIANCE TO STATE AND TOWN REQUIREMENTS FOR PERSONAL
SAFETY, PROPERTY PROTECTION, I.E. , SMOKE DETECTORS, SPRINKLER SYSTEMS,
itTC.
THE FOLLOWING DEPARTMENTS MUST SIGN OFF, IN THE RESPECTIVE ORDER, PRIOR TO BUILDING INSPECTOR
ISSUING THE REQUIRED BUILDING PERMIT:
REVIEWED BY:
1. WATER DEPARTMENT w C, • 1 S DATE: 9 - 7--5 '41-5 N/A:
2. ENGINEERING DEPARTMENT: DATE: N/A:
3. CONSERVATION: _ 21" (, �'A� DATE: r/- 9. N/A:
4. HEALTH DEPARTMENT ` `O��Q5 N/A:
5. Ai5/DRitfr- eoAiMIS, :5,VerJ.!'��..;, 1,' DATE:
-� ''-Ty3 _
INDUSTRIAL AND/OR Co II ERCIAL PERMITS
5. WIRING INSPECTOR:.; ; �„ DATE: OCT 15 1993 N/A:
6. PLUMBING INSPECTO b , ��,�a%/ i 1,,f� FATE: /Q-/5- - 415--:3 N/A:
7. FIRE DEPARTMENT +��, y�U z ,g„ ATE: 9s3 43 N/A:
... _i PLEASE NOTE
ALL STUMPS AND/OR BRUSH' MUST BE DISPOSED OF AT AN APPROVED SITE. A SIGNED RECEIPT FROM THE
DISPOSAL SITE MUST BE-SUBMITTED TO THE BUILDING DEPARTMENT PRIOR TO ISSUANCE OF THE BUILDING
PERMIT. (.^1
COMME•NTS: ► F'-‘'' L 4 0 1a v. It I . ' • ■• , 21 ) ■ , F.,►
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H.s ._._4t C'o�nMg;c PSR l}SSrcSOe REeeR.05 purr IN 1969 7—f,��Du/TIfT //l,
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Suggested Affidavit for Home Improvement Contractor Permit Application
For Ofn[e Use Only NAME OF CITY/TOWN
Permit No.
Date
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
MOL c.142A requires that the"reconstruction.alteration,renovation.repair.modernization.conversion,inprovement,removal,demolition.
or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than lour 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: �elito L_ Est. Cost 2 V 913
Address of Work , ?lp (//41.41/71C-i. gj t 7 Q z21 ✓C
Owner Name:
Date of Permit Application: ! Z2 - 5 3
I hereby certify that:
Registration is not required for the following reason(s):
_Work excluded by law
_Job under 31,000
_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:
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I hereby apply for a permit as the agent of the owner:
7— Jo-5', k .zar :r /OG62V
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
TOWN OF YARMOUTH
• BUILDING DEPARTMENT
. - CONSTRUCTION SUPERVISOR FORM
' ' PLEASE PRINT,: . .
• JOB LOCATION: g ;�„ " /i/H/ Lll/
' / �� — ��� �.
NUMB /�i r ei� /'Tf e ,VILLAGE . .
OWNER OF PROPERTY: ' • 66,D'c, JL rvY14i rILLA
CONSTRUCTION SUPERVISOR:taY0a7 /f. L-OV r7 :1,402Z 57 32,0-22j3
• . • . NAMELICENSE
21-22fj-
NAMELICENSE NO. PHONE NO.
ADDRESS//1/2 Ji • LaS _ 6 .� egyl6 � AV /l ' / ' . -
/
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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
' CO2•LMONWEALTH, 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 109.1.1 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 DEPARTMENT. ' ' '. ' ' :
• I HAVE READ AND UNDERSTAND MY RESPONSIBILITIES UNDER THE RULES AND REGULATIONS ,FOR LICENSING CCI-
STRUCTION SUPERVISORS IN ACCORDANCE WITH 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 ct.rre t liability insurance pclicy or its substantial equivalent which meets the requirements of MCLth.152 :'.a
Yes _ No ❑ , .:
If you have checked y`s• please indicate the hype c average by checking the =re' ' . '
A liability insurance PC c'4 • Daher type of :.idemntty 0 Sand 0 • - ..'----• –•
ONNE INSURANCE WAIVER• I am aware that the licensee des ^ot have the insurance coverage required by
C`a of the Mass. Gen L:ws. aria that my signature an tars permit c:piic:tion waves this requirement
Check ane: •
. iip
l _air Owner" Agent
Sign VI: : C ner cr Owner 'Agent •
SIGNATURE: BUILDING OFFICIAL APPROVAL:
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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
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• 150A.
The debris will be disposed of in: -
/ or y ?azo✓1
(Location of Facility)
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Si_nature of Permit ApplzWnt
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Date
Date