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Home My WebLink AboutBLD-93-800 4 z. ,k:of-Y44. 4 /d�8/93 `: tr.ft4"8 TOWN OF YARMOUTH Feu, to/Nis I .. �` • TTA.CHL 5 ,4it0i Application for a Permit to Build No. $30 UPON FINAL APPROVAL f� /D��► MAP 1S LOT I 1 FEE MUST ACCOMPANY THIS APPLICATION. DATE &V"( 19 95 The undersigned hereby applies for a permit to build A/ /9� according to the following specifications 1. Name of property owner 1Dn.0 ct C-1 / C/VAel. Address /' 13.rAr//tonal/ Qc/ SI'ORfriowril 2.Name of Architect(if any) I-,,Tel. a Name of builder /41?A.a // �j4/ %N t Address 25' a pgnexril 4. License No. o402'cr Tel. 5152 -778-423 a 5. Name of Mason Address 6. License No. Tel. 7. Construction address )3 Ckelacavosid 10 S bizmcu7/I FloodDistrict i1 8. Date of subdivision Approval plain zone P0) L/6y) Zone i'<-� 9. Private dwelling Er Estimated Cost roty 3 DO NOT WRITE IN THIS SPACE \Al D•� ti' /o,� o Type of room No. 10. Multi family 0 0,300 . Aolycs oes v 1?uov.lrrotKS 11. Commercial 0 --ene-e--ici, ,A/ (gj. - -Kitchen 12. Other 0 asze--;eeeerrte,�f/�+w Dining Rm. 13. No. of stories v ,3S"��" Living Rm. --/o ,<i'n pgp Bed Rm. 14. Foundation — Full 0 Half g Crawl 0 Slab 0 fi ?_5-46-7) 3mc Bath 15. Materials — Wood g Cement 0 Other 0 Deck 16. Type of heat — Oil 0 Gas Z 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 lin- Side line . 25. H.I.C.R. No. 1D9- 19?- LOT RELEASED BY Signature i PLANNING BOARD Address .1 e-% 2 Date U . , a ' j /0/5</93 0 '. • TOWN OF YARSOUTH • BUILDING DEPARTMENT • CONSTRUCTION SUPERVISOR FORM ' ' PLEASE PRINT: in JOB LOCATION: C, C . 0 .1 t. �' ? � / ' NUMBER--.2, )': . • ST • T VILLAGE ' OWNER OF PROPERTY: ' �J AS. %�j.4l L. _ CONSTRUCTION SUPERVISOR: 4-,m ' ` •: a '• S 7 •r. • �/ 2 • • NAME . . LICE SE NO. , PHOYE NO. • . . ADDRESS: L• /-�� • .2J ` �- 1 424.1)J �L. 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 DE-SOLITION 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 DEPART`�NT. ' " ' •. " -• • • - I HAVE READ AND UNDERSTAND MY RESPONSIBILITIES UNDER THE RULES AND REGULATIONS ,FOR :.ICENSING CC:1- STRUCTION SUPERVISORS IN ACCORDANCE WITH SECTION 109.1.1 OF THE STATE BUILDING CODE. I UNDERST!_i: THE CONSTRUCTION INSPECTION PROCEDURES AND THE SPECIFIC INSPECTION AS CALLED FOR BY THE BUILDING OFFICIAL. . INSURANCE COVERAGE: • • - I have ayes current liatidity insurance pclicy or is substantial equivalent which mee!s"the requirements of MGL10h.152 If you have checked v_s• please indicate the type coverage by checking the app:cpriate box - '_'.:`' :t A liability insurance picky ikOther type of indemnity 0 •• • Bond • • OWNER'S INSUR NC:W ER:I am aware t the icensee dc_es not have the insurance cover-ge requirec by Chatter1 or Mals: e� L9•ws�ana th�y signature en t::s permit c:ptica!icn wanes this requirenier.t i (/✓///� • Check one: /` Ownerg, Agent❑ Signature of Owner or Owners gent C / • SIGNATURE .1 :U,iLDING OFFICIAL APPROVAL: • - - - --- ._ . ----.... .." _ . . .. _ r _ 1 Suggested Affidavit for Home Improvement Contractor Permit Application • For Omce Use Only..'. - r...r•c-:...vc�rc.: :.. .._ NAME OF CITY/TOWN . . . Permll No. Dale 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 elan 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 contractors,with certain exceptions,along with other requirements. - n \l {�g v.0 /�/ Type of Work: 14 C. ' � D �4 4 u lap 4�1 --Est: Cost 2170'0 Address of Work 13 —3 Etc.el t,JODS Q\ Owner Name: o vJ !4G I J Date of Permit Application: ILj OG-k q - 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 age of the Tier: 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 •• -14 (s) • - - - • • • r'=3 COMMONWEALTH OF MASSACHUSETT• S DEPARTMENT OF INDUSTRIAL ACCIDENTS . ._ . -- .• -.. 600 WASHINGTON STREET James a Campoeu BOSTON, MASSACHUSETTS 02111 • commissioner WORKERS' COMPEN ATION INSURANCE AFFIDAVIT • Itit C- rhtth A t (licensee/permittee) • with a principal place of business/residence at '� aIAA (City/Sate/Zip) do hereby certify, under the pains and penalties of perjury,that: [J I am an employer providing the following workers' compensation coverage for my employees working on this job. Insurance Company Policy Number kk1 am a sole proprietor and have no one working for me. [ J 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: r..r n- - - . . • Name of Contractor Insurance Company/Policy Number . . • Name of Contractor - 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 units io 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 50 00 and/ r imprisonment of p to one year and civil penalties in the form of a Stop Work Order and a fine•of S100.00 a day against m . Signed this v/� /Z day of • /4 001 19 J• - Liar.seeiPermitrec' • Licensor/Permit:or