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Home My WebLink AboutBLD-93-806 'OF•Y`j4 ` T 1 o TOWN OF YARMOUTH- o►��''' NCo es,,"k. .` fl Application for a Permit to Build No. g° a jo-aa- / 3 UPON FINAL APPROVAL MAP 1 q LOT 5/ 3 0 FEE MUST ACCOMPANY THIS APPLICATION. DATE mar 19 93 The undersigned hereby applies for a permit to build /VaP7/9-3 according� to the following specifications 1,11.-Came of property owner . t Tel. 77s'- 6750 Address t3K,a4L.r -) V' - you-rad kil.k 2.N meofArchitect(ifany) Tel. t3:Name of builder Freinct s iTP4Son Address 6c'7 N. rnc'n 6 L fil,n 0c0 4. License No. Tel. 5. Name of Mason Address 6. License No. Tel. instruction address B era FloW od-di"ed Distr 8. Date of subdivision Approval plain zone C Zone ht P-S 9. Private dwelling 0 ystimated Cost - DO NOT WRITE IN THIS SPACE Iro-tF. A"(4 _ Type of room No. 10. Multi family 0 IV 0-4-(00-cx) r /`j'CPFii/L I 11. Commercial 0 J✓Ef/T�CI�� o�� Kitchen 12. Other ❑ ta-S- 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 0 Other 0 Deck 16. Type of heat — Oil 0 Gas 0 Electric 0 Other ❑ Closed porch 17. Garage — 1 0 2 ❑ Family Am. 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, istance back from line or street From rear lot line Side line i /2'5. H.I.C.R. No. /0733-9 LOT RELEASED BY L-Signature l PLANNING BOARD Address Date - - - - Suggested Affidavit for Home Improvement Contractor Permit Application • For orrice Use Only NAME OF CITY/TOWN Permit No. Dote AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application MGL e.142A requires that the"reconstruction,alteration.renovation.repai r,_moderniration.conversion,inprovement,removal.demolition. or construction of an addition to any pre-misting owner-occupied building containing at least one but not more than four dwelling units....or to structures which are adjacent to such residence or budding"be done by registered contractors,with certain exceptions,along with other requirements. Type of Work: RCrDP= Dtrc.,2 Est. Cost 2-760• — Address of Work 5-6• �iLONl7/Nat 'Owner Name: /4?rile- �// at ate of Permit Application: /0/S-/`9' 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 agent of the owner: Contractor l [r/o73a-3 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 _— e • . • DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 WASHINGTON STREET James J Campoeu BOSTON, MASSACHUSETTS 02111 • • Como ss over WORKERS' COMPENSATION INSURANCE AFFIDAVIT • • • • ( , Fre4tA,ts C . Mels o.. (licensee/permirtee) • withhaa incipal place of business/residence\ an • 6 4 n (`�.M0,,I4 6l- M 141,11(4.0 /hilt— °YEA(JP (City/Sate/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. • Insurance Company Policy Number (Priam a sole proprietor and have no one working for me. - . [ ] I am a sole proprietor,general contractor or homeowner (circle one) and have hired the contractors listed below - whohavethe following workers' compensation insurance policies: ✓F. G &kb.' Car. icy —> r 6 Name of Contractor . / Insurance Company/Policy Number.. . Name of Contactor. • 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 tutus 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 lnsurana 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$100.00 a day against me. Signed this v / day of � GT , 19 9 3 Licensee Permtaec' Licensor/Permirror TOWN OF YARMOUTH • BUILDING DEPARTMENT . CONSTRUCTION SUPERVISOR FORM ' PLEAS PRINT: ' • ' . . . B LO ATION: 5•�• roA.J.t..,c..1 •. t i . vW'[Aw4'U NUMBER STREET 1 VILLAGE ER OF PROPERTY: ' /• ',-- .• .Mv1'r LSTRUCTION SUPERVISOR: • Fne,,ctc 0e(��_[,� O�t7 �f"S b ' Y330t--n43 • . NAME . .. LICENSE NO. • . . PHONE NO. • ADDRESS: . • .. 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 L*MONWEALTH, 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 .1,110 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. ' . . - y • • • • . 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, REIOVAL 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 DEPART`ENT. ' : '. ' ' . = " ' . • . • • I HAVE READ AND UNDERSTAND MY RESPONSIBILITIES UNDER THE RULES AND REGULATIONS ,FOR :ICENSING CCN- STRUCTION SUPERVISORS IN ACCORDANCE WITH SECTION 109.1.1 OF THE STATE BUILDING CODE. I UNDERSTA;: THE CONSTRUCTION INSPECTION PROCEDURES AND THE SPECIFIC INSPECTION AS CALLED FOR BY THE BUILDING OFFICIAL. . I have a current liability insurance peticy or its substantiae equivalent which meets the requirements of MGL1t;h.152 :�'..1.""`' :• •:-Yes ❑ _ — No ❑ y • 7:•z7.44...L r_: If you have checked As. please indicate the type c average by checking the ap-r cpriate bex =`f _" 'r ' A liability insurance pc.icy 0 C:her type of :.idemnity❑ ;6- •- Bond 0 •• - — OWNER'S INSURANCE WAIVER: I am aware that the acensee deer rot have the insurance coverge•require^_•`r. Chaster 152 of the Mais: General L-ws• ana that my sigha:ure on this permit :cpticticn waxes this requirerr:en • ' • . • • Check one: • _ , _Owner° Agent 0 S.gnature at Owner or Owners Agent ' 1 SIGNATURE: ��n - r BUILDING OFFICIAL APPROVAL: