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Home My WebLink AboutBLD-93-796 .F•YHji,. w* O .bl9I93 - f4 . o TOWN OF YARMOUTH Y • ;TAG MC 1 • �� V40,,,,,„).S a., Applica ion for a Permit to Build No. UPON FINAL APPROVAL /0--/9-9---5 MAP /3 LOT a -Se- FEE srFEE MUST ACCOMPANY THIS APPLICATION. DATE /d//9 19 7,3 The undersigned hereby applies for a permit to build MA 9/93 according to the following specifications 1. Name of property owner cT«f ,/'7'A /N Tel. 771_7 99 Add ress L`d `39 /i7re>rYO,t-)X6-6'/JO z2' VAl' 2.Name of Architect(if any) Tel. 3. Name of builder _Jc'////) (>lk' Address 77607)//1/52/)64710- ii-1W 4. License No. Tel. <39rt 5792f 5. Name of Mason Address 6. License No. Tel. 7. Construction address 30- 32 Ci✓ fine ).N • Flood District le- 2� 8. Date of subdivision Approval plain zone fit .- (at. i/ 7 Zone 9. Private dwelling 0 Estimated Cost DO NOT WRITE IN THIS SPACE 10. Multi family 0 z rdd Sr/Lip P_ Wrec a Type of room No. e PAH R I 11. Commercial 0 Ce-0/5" Kitchen 12. Other ❑ - Dining Rm. 13. No. of stories Living Rm. Bed14. Foundation — Full 0 Half 0 Crawl 0 Slab 0 'tea s',crt) Ba hRm. 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 ❑ 2 ❑ 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 lot line Side line • 25. H.I.C.R. No. /0049--2- . LOT RELEASED BY Signature ,71 ��t PLANNING BOARD Address Date • ' Suggested Affidavit for-Home Improvement Contractor Permit Application For once Use only NAME OF CITY/TO WN Permit No. .. Date AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application MGL c.142A requires that the"reconstruction,alteration.renovation,repair,modernization.conversion,inprovement,removal.demolition. or construction of an addition to any pre misting owner-occupied building containintat 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: er)i / Est. Cost2f?0�aa • Address of Work `n — 7 A7A(/rNaE/I 'r Z,v /�(/ Vjw Owner Name: (%oK F/yy Date of Permit Application: ay/ 9/93 I hereby certify that: Registration is not required for the following reason(s): • _Work excluded by law _Job under 51,000 _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: /09/9 3 cilia/o . 'Oik i4/199-7. 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: • • J' ' J • w r?Q 32 / • ' JOB LOCATION: VN✓,t/(/.P✓b�f� Lam-- VA € . • NUMBER • . • ' •• . STREET VILLAGE OWNER OF PROPERTY: ' (727/3-- ' - 7,7641:2")(4/ CONSTRUCTION SUPERVISOR: �A!Y/D Grd - ' • - •j g .41— - NAME . .. LICENSE NO. PHONE NO. • ADDRESS: 7y4 Sl U i) Aar' • /c 7X/ YC2 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 ' COI•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 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 DEPARTM.E.NT. -' I HAVE READ AND UNDERSTAND MY RESPONSIBILITIES UNDER THE RULES AND REGULATIONS ,FOR :ICENSING CC:i- 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 currenn liability insurance pclicy or its substantial equivalent which meets the rients of Mth.152 :' - i ' : Yes W :. :: No ❑ - .. .. _. equrem CL If you have check_ed v`s• please indi - e the type caverns by checking the ap'rcpriate box C 'Yof4/ • Aliiabilit insurance clic _. ..:_ tie-P 1 Other type at:ademnity 0 .bond ❑ •� °-• • OWNER'S INSURANCE WAIVER:I am aware that the licensee aces: not have the insurance coverage required:^i- Chapter 152 of the Mass: General Lw a that my signature cn this permit ::p.icaticn waves this requirernec: / • Check one: c / - / f • Owner" Agent❑ ' ' ....g..a.Ra ct caner c•caner s Agent • SIGNATURE: BUILDING OFFICIAL APPROVAL: • • 5= =` COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF INDUSTRIAL ACCIDENTS _ .. ... _ .- . fes ' 600 WASHINGTON STREET .. __ • James Campoeu BOSTON, MASSACHUSETTS 02111 • conm:ss,oner WORKERS' COMPENSATION INSURANCE AFFIDAVIT • • • ��l//CJ (i tel (licensee/perminee) • • with a principal place of business/residence an • 7,FSA-72/ii/a) >9/Ws- ss(9 /n /7729 z // — - (City/State/Zip) do hereby certify, under the pains and penalties of perjury,that: rr. _ [) I am an employer providing the following workers' compensation coverage for my employees working on this job. ( 17J2 �z/7YvLC.C.5(/.9lM/ zreg V6- .7 29 Insurance Company Policy Number ) I am a sole proprietor and have no one working forme. [) 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: _, ,__= _ - _ - __ Name of Contractor Insurance Company/Policy Number . . . Name of Contractor •• . Insurance Company/Policy Number - - • Name of Contractor Insurance Company/Policy Number . _ D 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(CL C. 152.sect. 1(5)), application by a homeowner for a license or permit may evidence the legal sums 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 impoiition of criminal penalties • consisting of a fine of up to SI500.00 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 /9 TN day of OC7' , 19 4-' . /<_ l _Ai 41.9 LicenseeiPermittet' LicensoriPermirror • •• . • • 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 Ill, S ' 150A. The debris will be disposed of in: - - • • (Location of Facility) • • • a�7e 'r Signature of Permit Applimnt / 9 �/ / Date • • • r •