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Home My WebLink AboutBLD-93-795 of•YgR _ ern Io/i9/c3 � t,g TOWN OF YARMOUTH • MATTACMEES 4,„,,,„,.*0, Application79X for a Permit to Build No. UPON FINAL APPROVAL 70-)q1-y3 MAP %3 LOT Z -y FEE MUST ACCOMPANY THIS APPLICATION. DATE /e1//, 7 93 The undersigned hereby applies for a permit to build //9/ 93 according to the following specifications 1. Name of property owner ;D/z)//U afinaz. Tel.4/-77`‘217-# Address 2 Vi0L-1.3042,416-A- /a227_ 7W3 2.Name of Architect(if any) Tel. 3. Name of builder 4 V') Address 77S672d/67-1) er" 1/X'P 4. License No. Tel. 899.-S9•Z.k' 5. Name of Mason Address 6. License No. Tel. 7. Construction address c2111' 14 A)C.h0R q9a LiU• to • Flood Di ict 8. Date of subdivision Approval plain zone F//7-at, i/' Zone 9. Private dwelling ❑ Estimated Cost DO NOT WRITE IN THIS SPACE 10. Multi family 0 y lJ 5774/P '/��,Zc aF Type of room No. Gf.� POPE/ $4-4.7--ii ajeci. n-tt f 11. Commercial 0 -Kitchen 12. Other ❑ Dining Rm. 13. No. of stories .Z 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 ❑ . Closed porch Family Rm. 17. Garage — 1 ❑ 2 ❑ • 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 lot line Side line 25. H.I.C.R. No. /009 ' LOT RELEASED BY Signature ,/,'./.4/Gt%,77- PLANNING BOARD Address Date • TOWN OF YARMOUTH • BUILDING DEPARTMENT . CONSTRUCTION SUPERVISOR FORM PLEASE PRINT: JOB LOCATION: 74'Ac�Yl'4e,tre /PP /AV?- • NUMBER STREET . . VILLAGE • OWNER OF PROPERTY: ' /�roz2.Al .42,09 Z CONSTRUCTION SUPERVISOR: 4G� � i `39�f-5 } LICENSE NO. PHONE N0. ADDRESS: • 7P- ,SLS-Aviz�L) ADA— 50 1/ire •j47 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 BE 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 DEPARTM1NT. . ' ' ` - "' .. • I HAVE READ AND UNDERSTAND MY RESPONSIBILITIES UNDER THE RULES AND REGULATIONS ,FOR LICENSING CON- . STRUCTION O N- 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 current liability insurance pclicy or its substantial equivalent which meets the requirements of MGL1Oh.152 Yes No ❑ It you have checked yes. please indicate the N"pe"c average by checking the ap_r cpriate bcz . - `, -•"' A liability insurance c::/ . • 0:her type of :ademnity L3cnd O -•—••. •••••••-: .. OWNER'S INSURANCE WAIVER:1 am aware that the licensee d:es not have the insurance coverage requirecib;r. Chapter 152 of the Mass. General L-ws, ana that my signature on tn:s permit ccciicaticn waxes this requirement . / • Check one: /`/ • w Owner; Agent 0 SiSoat a of Owner cr Owner s agent • SIGNATURE: tai BUILDING OFFICIAL APPROVAL: • ' Suggested Affidavit for Home Improvement Contractor Permit Application For office use only NAME OF CITY/TOWN Permit No. Date AI-tIDAVIT Home Improvement Contractor Law Supplement to Permit Application MOLe.ICA requires that the'reconstruction,alteration.renovation.repair,modernization.conversion Inprovement,removal.demolition. or construction of an addition to anv pre-existing 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 exceptions,along with other requirements. Type of Work: 7C // � ,/ Est. Cost )r�0� Address of Work 2 tyA6C/YOZ/96 r G/' Gfl%1'e A2x Owner Name: 6r9/1l/f,) ,C/P1'1eA- Date of Permit Application: MA9/f�C3 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 of the owner: / 03 7)),l//e2 / 9a-9 Dat Contractor Name Registration No. OR: • Notwithstanding the above notice, I hereby apply for a permit as the owner of the above properly: Date Owner Name • • COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF INDUSTRIAL-ACCIDENTS • - ,, � 600 WASHINGTON STREET James Camvoep BOSTON, MASSACHUSETTS 02111 • Commissioner WORKERS' COMPENSATION INSURANCE AFFIDAVIT • I, c�i1w/7I 7Y (licensee/permittee) • with a principal place of business/residence at: • yr iv 4 ZS— i (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. • • .O/A7.;?/l✓n' t--Ce(51Yri.7v 2 lot• 9'S'6-,.2937) • 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: >_ =- - 1 :.• c . • 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:.Pleue 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 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 S100.00 a day against me. Signed this /9 day of QG"T , 19 7? Licenscc/Fermirtei• Licensor/Permittor • • . . • • • • 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 bedisposalof in: • • 1XIP✓�aJltriS� .:5- IssA7G (Location of Facility) • • • "(04. ,moo Signature of Permit Applica t Date