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Home My WebLink AboutBLD-93-802 0,e. Fes- ""$/60',S, 0 TOWN OF YARMOUTH ro/sells ,x f " .: W $ Application for a Permit to Build. No. 902 UPON FINAL APPROVAL ` ()'a` MAP 6-.3 LOT M / FEE MUST ACCOMPANY THIS APPLICATION. DATE /d�.�?419 9� The undersigned hereby applies for a permit to build /72-//9_3 according to the following specifications /D �//�J3 1. Name of property owner /� a ��Nf �!/L� � / / Tel.7d4a 7,?S Address 7c,? �J,4`i,��,�J%irG/ �t7 +-� 2.Name ofArchitect(ifany) / Tel. 3. Name of builder -4,-/_ �i ,.. ... l Address '` ii A- , . . � i.'cl8 4. License No. rs' z' Tel. . f� as , 5. Name of Mason Address 6. License No. Tel 7. Construction address 7 Sys 4 �•�-�i Y (�--�l a Flood L Z nteicthare- 8. Date of subdivision Approval plain zone 9. Private dwelling 0 Estimated Cost DO NOT WRITE IN THIS SPACE Type of room No. • 10. Multi family 0 eb p�-4es / 11. Commercial 0 Kitchbn 12. Other RI,,. _� $ac Dining Rm. 13. No.of stories NEM A ( Living Rm. Bed Rm. 14. Foundation — Full 0 Half 0 Crawl 0 Slab ❑� 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 0 2 0 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. /OO/S9' LOT RELEASED BY Signature _02,..- ,-... .----43,i/c PLANNING BOARD Address �3-)- 2 /4, q-V ,-/ Date 7.4.1k4p-r-4 ...%S„ 1 Suggested Affidavit for Home Improvement Contractor Permit Application For mire Use Only NAME OF CITY/TOWN • Permit No. Date AI+ I )AVIT Home Improvement Contractor Law Supplement to Permit Application MGL e.142A requires that the"reconstruction,alteration.renovation.repair,modernisation.conversion.inprovement,removal.demolition. or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelli n g 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: f/1 Est. Cost 20o-a. Address of Work //� ? ^;' � l•�rL ! / �"`� Owner Name: "��4arcil../�� .••••'' 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 _Omer (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: 92' G %�l v U'n / /?d ift‘ 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 • COMMONWEALTH OF MASSACHUSETTS -- pi. • • •DEPAR:'MEN •OF INDUSTRIAL ACCIDENTS - 600 WASHINGTON STREET James: Campbell BOSTON, MASSACHUSETTS 02111 Commss,oner WORKERS' COMPENSATION INSURANCE AFFIDAVIT • • .4•27:1 (licensee/perminee) • with a principal place of bus ess/residence at: ;232- d-d It!"-i•tf-e 74a4 at-CS --_-.. — (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. D74ay1, Insurance Company Policy Number [ l am a sole proprietor and have no one working forma • • [ j --I am a sole proprietor, general contractor or homeowner (circle one) and have hired the contractors listed below —:n. who have the following workers' compensation insurance policies: •• ,1 7".. . • • Name of Contractor Insurance Company/Policy Number.. . . Name of Contractor Insurance Company/Policy Number -..• - •- -• Name of Contractor Insurance Company/Policy Number - Q 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(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 1 understand that a copy of this statement will be forwarded to the Department of Industrial Accidents' Office of Insurance for overage ' verification and that failure to iccure 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 5100.00 a day against me. Signed this �✓Iday of 7C-' , 19 ` 3' Licensee/Pcrmine; Licensor/Permirror ' TOWN OF YARMOUTH • BUILDING DEPARTMENT . .r 4',CA CONSTRUCTION SUPERVISOR FORM PLEASE PRINT: // JOB LOCATION: 7,2 �jy). � *.as;:•v,.. 6� NUMBER . . , STREET VILLAGE OWNER OF PROPERTY: ' _ _. _2,44 . , `, CONSTRUCTION SUPERVISOR: _Asei�' .2,O.re 9,CdG V • • N.,&"' LICENSE NO. • PHONE. NO. • : � ADDRESS: /�//. • 9�. % 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 ' • COb•L4ONWEALTH, 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 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 L`2I.EDIATELY CEASE UNTIL A SUCCESSOR LICENSE HOLDER IS. SUBSTITUTED ON THE RECORDS OF THE BUILDING DEPART"ENT. " " . ' • " ' ' I HAVE READ AND UNDERSTAND MY RESPONSIBILITIES UNDER THE RULES AND REGULATIONS .FOR :ICENSING CCI- • STRUCTION SUPERVISORS IN ACCORDANCE .ITH 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 INSURANCE COVERAGE: • : . " . ;�. have a currVability insurance policy or its substantial equivalent which meets the requirements of MGLth.152 -;'•:- . Yes _No ❑ If you have decked v_s, please ireicate the h;pe coverage by checking the ap :cpriate box. : _ ;' .r '- • A liability incur era pc:icy Q� '/ other type of ademnity 0 i Bond 0 .. - ' .• — OWNER'S INSURANCZ 1'twAIVER:I am aware that the rcensee dcei rot have the insurance coverage required by C`apter152 of the Mass: GenerJ L:ws, ana that my signature on this permit ::plication wives this requirement , . • Check one: •• • Owner: Agent 0 ' S:gnaeme of Owner or Owners Agent ' SIGNATURE: BUILDING OFFICIAL APPROVAL: