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Home My WebLink AboutBLD-93-798 F•YEtit a?yr,tla//P/4s " `= " L .. TOWN OF YARMOUTH ��^^� T � 4(i� l0�/9�93 ` MIITTMCM[ 5 04°"°"^'" 0i Application for a Permit to Build No. 792 UPON FINAL APPROVAL I �3'S / MAP IO LOT a/CV FEE MUST ACCOMPANY THIS APPLICATION. DATE /v/iy9 3 19 9 3 The undersigned hereby applies for a permit to build /V*93 according to the following specifications . Name of property owner Vi'eta RLetaLetam a.wt gm Tel. C07-s'v c'--2X65' Address I 2 I Per, sr- ; /3-7atari 4,-.e , u4a, 0AiVI/ 2.Name of Architect(if any) Tel. dame of builder .la e C'.4 c4 i s- a,. 6h •ddress 5 SS VO4wom 1t PCI, h/nuuk.s� WO_ Rum - 4. License No. Tel. 5. Name of Mason Address 6.License No. Tel. tel. Construction address it) Pa,k sr W. V �wt.... . Flood District 8. Date of subdivision Approval plain zoneZone 1 C.- "y S- 9. Private dwelling 0 Estimated Cost DO NOT WRITE IN THIS SPACE 10. Multi family ❑ c------1.2.. o c�,' -/suc w L fire, Type of room No. r1' Ca.nc KE IOVIZ.s on r 11. Commercial 0 Kitchen 12. Other ❑ Dining Rm. 13. No. of stories '�S�u-c� 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 ❑ 2 ❑ Family Rm. Sun room la 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. istance back from line or street From rear lot line Side line (45. H.I.C.R. No. /o3976 LOT RELEASED BYignaturea C J C� ✓� PLANNING BOARD Address/9cc �o,_.«.,,.-..Yl, R Date ' ii2auNil/ $4 , ono / • • ' Suggested Affidavit for Home Improvement Contractor Permit Application For Office Use Only NAME OF CI—TY/TOWN Permit No. Delo • AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application MGLc.142A requires that the"reconstruction,alteration,renovation,repair,modernization.conversion inprovement,removal,demolition. orconstruction of an addition to any pre-existing owner-occupied building containingat 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: /14Ja /car/ /o N Est. Cost /2 0791 Address of Work /0 Pa, e Sat GJ, /ea CAA.0_k() Il Owner Name: t/tet —t ntictuJ cm Date of Permit Application: /o//9/ 9 Z 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: /0/9/93 �Qtt^RJ C fo/hit* ; rN 103 V7‘ 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 DEPARTYINT • '' CONSTRUCTION SUPERVISOR FORM PLEASE PRINT: ' - . '/ JOB LOCATION: /0. r� t( S t• • (Lu U1 tl Lt'F k{ • NUMBER 1' ' . . ' . STREET, . . . VILLAGE ' .OWNER OF PROPERTY: ' Vt ct 0 2. S W/0. to f dm SUPERVISOR: • J1ai,Q� C go (JS Wt ITN • (03 97 6 775-1214 • N LICENSE NO. PHONE NO. . ADDRESS: y SS Vaaiacot4.1-4 Ed.. f J-f/atnUfJ�' U'la., 0.2 6 0 1 . 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 DMIOLITION AS REGULATED BY SECTION 109.1.1 OF THE - CODE AND THESE RULES AND REGULATIONS. IN THE EVENT THAT SUCH LICENSEE IS NO LONGS SUPERVISING SAID PERSONS, THE WORK SHALL IMMEDIATELY CEASE UNTIL A SUCCESSOR LICL1SE HOLDER IS SUBSTITUTED ' • . ON THE RECORDS OF THE BUILDING DEPARTMENT. ' ' ' ' ' . •' ' . • 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 UNDERSEA::: THE CONSTRUCTION INSPECTION PROCEDURES AND THE SPECIFIC INSPECTION AS CALLED FOR BY THE BUILDING 0£FICLAL. .....;, INSURANCE COVERAGE: . • . :: • - . have a current liability insurance policyor its substantial et uivalent which mee's the re.u.irements of MGLth152 . It you have checked Is please indicate the P,pe c average by checking the ap.rcpriate bcx. • ' :" li . . . - „ ., A liability insurance ;tic,/ �. C ter ,�, I . . • type of :.idemnity ty/� 8cnd ❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee dere rot have the insurance coverage required C`apLr 152 of the Mass. General Laws. ana that my signature on tn:s permit baciic_ticn waves this requitemer..L _ . • Check one: • ', Owners Agent 0 Sigra:ure of Owner cr Owners Agent ' SIGNATURE 1/S7222-•22-•"# BUILDING OFFICIAL APPROVAL: l f • eoQn /ont OtikWacdauaet • A o € _'a HOME IMPROVEMENT CONTRACTORS REGISTRATION '_ Board of Building Regulations and Standards �a_ One Ashburton Place - Room 1301 Easton , Massachusetts 02108 HOME IMPROVEMENT CONTRACTOR _ Registration 103476 Expiration 07/08/94 Type - PRIVATE CORPORATION idladsaitwaz =�=c HOME IMPROVEMENT CONTRACTOR i :� Registration 103476 Cape Cod Insulation t•''iir1— @ Type - PRIVATE CORPORATION James C . Goldsmith Expiration 07/08/94 455 Yarmouth Rd . Hyannis MA 02601 Cape Cod Insulation rV (� _ •, 'lases C. Goldsiith 455 Yarmouth Rd. ADWBSTRATOR Hyannis MA 02601 -1-- = . _ _ fl E t^' ' P • DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 WASHINGTON STREET • • • James J CamDoe�: BOSTON, MASSACHUSETTS 02111 • comm ssroner WORKERS' COMPENSATION INSURANCE AFFIDAVIT • • 1, J7—c1 e C rt., if/A4 l a - 4 uJ ¢.0 /dvt Ac- (licensee!permittee) • with a principal place of business/residence at • • • �1 y<S Veuu.to-,AA Rei. ii>4umil, (041 0.2601 ' /(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. /�o1'e t J ti /r1 G7 OR F /L& . Insurance Company Policy Number ( 3 1 am a sole proprietor and have no one working for me. .. .. — -- - -- - - ( ) 1 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 . . - . 7.2. - - • 1 • Name of Contractor Insurance Company/Policy Number . - 0 1 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 Aeddenu' Office of lnsurantz for overage verification and that faiiure to iccure coverage as required under Section 25A'of MGL 152 can lead to the impoiition of criminal penalties • consisdng of a fine of up to S1500.00 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 I0" " day of O O( ' r 19 9l3 L1,_0:_a as eelPermirtet. LicensoriPermiror