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Home My WebLink AboutBLD-93-799 -• iG i? ' . Fgt.) o TOWN OF YARMOUTH ° Y taM TTMCMEES4. , Vo"`°" '°° ' Application for a Permit to Build No. l j0 ---c21-1 / UPON FINAL APPROVAL al MAP �P LOT FEE MUST ACCOMPANY THIS APPLICATION. DATE .,i, �K�� M019 The undersigned hereby applies for a permit to build /(yam-//93 according to the following specificati ns 1. Name of property owner (1r-g+46-1• L4 KTel. Address I� C�-l. a.C1-tan/• al/ 2.Nameof Architect(if any) Tel. 3. Name of builder l4 tufn,= 2 U • f1L (.Address A • 4s CirticL�vt/y 4 4. License No. °SD 576-c Tel. v 5. Name of Mason Address 6. License No. Tel. 7. Construction address /C C is 11 Flood District R_ ti 0 8. Date of subdivision Approval plain zone 9. Private dwelling 0 Estimated CostDO NOT WRITE IN THIS SPACE Type of room No. 10. Multi family 0 f g .( 5�o� REp41 p S I 11. Commercial 0 )0216, y P i, ,•/ ,C• • Kitchen 12. Other 0 II'' v , " �/�chit, 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 ❑ Other 0 Deck 16. Type of heat — Oil 0 Gas 0 Electric 0 Other 0 Closed porch 17. Garage — 1 0 2 ❑ Family Rm. Sun room la 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 2a Distance from nearest building: Front Ft. side Ft. side Rear 24. Distance back from line or street From rea lot li Sid 'ne 25. H.I.C.R. No. /87-f?7- 14, LOT RELEASED BY Signature --%'r PLANNING BOARD Address Li as3 2 V. yrkaa-0,44 Date TOWN OF YARMOUTH - • BUILDING DEPARTMENT • CONSTRUCTION SUPERVISOR FORM PLEASE PRINT: .- . - JOB LOCATION: • �$ G -� rJ gJ S ' liditgdkeA NUMBER RE`,ETv VILLA . ', .OWNER OF PROPERTY: : '' b ^i-ocG_-• Vt1 I -+T T.( . . CONSTRUCTION SUPERVISOR: lr l ta(� V 1 L 4 i` cLi� Z2 NAME NIEL N0. PHONE N0. ADDRESS: ' 4 .,, et • id. DI " - ' : . .' . : . 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 2.1.5.3., 2.15.2 OR `2.15.3 OR ANY . . OTHER SECTION OF THESE RULES AND REGULATIONS AND ANY PROCEDURES, AS AMENDED,' SHALL 3E SUBJECT '7 TO REVOCATION OR SUSPENSION OF LICENSE BY THE BOARD. :.; ' ` 2.16. 'ALL BUILDING PERMITAPPLICATIONS 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 I:LMEDIATELY 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 CCt- STRUCTION SUPERVISORS IN ACCORDANCE WITH SECTION 109.1.1 OF THE STATE BUILDING CODE. I UNDERSTAN r. THE CONSTRUCTION INSPECTION PROCEDURES AND THE SPECIFIC INSPECTION AS CALLED FOR BY THE BUILDING 0£FICIAL. INSURANCE COVERAGE:...,.::... •- --7:7:7.:::::.:E: »~'-`>4 )- 471,7171,::::::7-'5C3:•;. L,. ._:>; o i ri-ry -'::::•.•;. : I have a cvrren liability insurance pclicy or its substantial equivalent which meed the requirements at M�L1bh.152 '... k�:<:; `'i'.'':: :.Yes • .=t No D - .. . ,. - 3I,71 _ ._ If you have checked its., please indicate the type coverage !rycheckingtheap^rc.pr_ate,bcx' k"11-)"'2- -'' = A liability insurance pciicy Other type of ademnity 0 - -Bond 0 - `=&'- ^^•`t ''-'- • OWNEA'S INSURAN l' _. .. a _ . .. _ CE WAIVER:I am aware that the licensee doea not have the insurance coverage-teequired_y Chapter 152 of the Mass. General Laws, ana that my signature on tats permit ccplication waives this requirerrer.: ---_ . - •• Check one: ' ' - OwnerD Agent 0 • - Signature of Owner or Owners nt ' SIGNATURE: /7/47/7/47r : . G OFFICIAL APPROVAL: . 1 a-- - COMMONWEALTH OF MASSACHUSETTS DEPARTMENT:MEl`T OF INDUSTRIAL ACCIDENTS 600 WASHINGTON STREET James Campoeu BOSTON, MASSACHUSETTS 02111 . Comm•ss ones WORKERS' COMPENSATION INSURANCE AFFIDAVIT • e• 1 1• (74—,9-7(1 (liccnsee/perminee) • with a principal place of business/residence at. (City/State/Zip) do hereby certify, under the pains and penalties of perjury,that: .__ _ _. •-7-217: ,:.-..-7-.-77T7 __— =- _ .___ - [) I am an employer providing the following workers' compensation coverage for my employees working on this job. Insurance Company Policy Number 'f-I am a sole proprietor and have no one working for ma - ( ) 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 Contactor - • Insurance Company/Policy Number • Name of Contractor Insurance Company/Policy Number ..- • •` . 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 uniu 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 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 51500.00 and/or imprisonment of up to one year and civil penalties in the form of a Stop Work Order and a fine of SI00.00 a day against me. �,� � n/ Signed this a 4S . L.. day of C7 'i` , 19 G ift /ova • Licensee Permit•.ec Licensor/Permittor Suggested Affidavit for Home Improvement Contractor Permit Application For Office Use Only NAME OF CITY/TOWN • Permit No. Date • AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application MOLe.142A requires that the"reconstruction,alteration.renovation.repair,modernization.conversion.inpmvement,removal.demolition. or construction of an addition to any 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 cont ors,with certain exceptions,along with other requirements.• f� Type of Work: Q 1 p I�eQyEst. Cost 5��/ Address of Work t5 �t 7t...J ' �1r � Owner Name: • 2e-g-o-$57 14 7) X• 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 as the age of th, ow/-r: 10" 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