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Home My WebLink AboutBLD-93-808 .. ..t.�,q G�7 --/%tel J3 < ` %*Q r it) , TOWN OF YARMOUTH oKF� 10/19/95t Y._. 1a kti N " ' �` Application for a Permit to Build No. gO c1 /0 , ,q3 UPON FINAL APPROVAL . MAP oC to LOT /6 FEE MUST ACCOMPANY THIS APPLICATION. N DATE ✓s The undersigned hereby applies for a permit to build /U/off- 9.3 according to the following specifications ._ /v/.W93 Name of property owner ' m IJt; 5 t-'er G Tel ficib— 53 Address .S 6 Am ng R D \QEcs Yn2 moon-1 2.Name of Architect(if any) Tel. \3. Name of builder Ii Nrtr43or ()aro PnowLrs Address (ZO Gear t ,s 12n S's Dann 4. License No. oyCI 3 Sr Tel. 76 0 l'LCD 0 5. Name of Mason Address 6. License No. Tel. 7. Construction address SC, AM be ?o 61/43 Y&t.r-c oo Ti Flood District Date of subdivision Approval plain zone e- Zone 4_62s- 8. 9. Private dwelling 0 Estimated Cost 41-!\4, DO NOT WRITE IN THIS SPACE 10. Multi family 0 (Z7 O rip 10 cc tf /0,Ao to Type of room No. i6/f9/93 12E5 11. Commercial 0 _ Kitchen 12. Other qt.- Dining Rm. 13. No. of stories c3�oc� L ad�'� Bed BeinR Rm. d Rm. 14. Foundation — Full 0 Half 0 Crawl 0 Slab tgl. 4 )c • en te,9t- 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 18. Swimming pool - Size Garage 19. Storage shed icSize 8 £ IZ Shed S`)( ) 2, 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 17- No. of feet side S No. of feet rear I 2-- 23. Distance from nearest building: Front Ft. side Ft. side Rear 24. Distance back from lineor s reef From rear lot line Side line 25. H.I.C.R. No. /6937 /� LOT RELEASED BY Signature— uc �lJdAt'Kr�erhrvruru,e PLANNING BOARD Address S(, (-I OILDs, gcf, _. Date N (AW r/j2McDnrH 40h 9/93 L 1r PLOT PLAN • •4 FOR LOT ); • Indicate location of garage or accessory building Additions with dashed lines . Sewerage disposal (cesspool) e . . Wpll I (lot ft. rear) I — — - Abuttor's6 I Abul I Name Name - n Loti. Lot RE-Alp YARD If this isaI - Zo Ift corner lot, J • . . . . .j 1 corn write in name . writ of street. - rAli. I name ;; ? G othe • ie • 0 iv stye m ,n , . . SIDE YARD SIDE YARD • • HOUSE • fi FT. r, • . 0 • FT°, • • • 0 • . • I . . . I • 3. SET BACK • ft 0 I o I I p • • (lot ft. frontage) .• \ / \ AP105 --R00 . \ / \ / (NAME OF STREET) / / �\ \\ \-Information • / Supplied by it !AI 1 . _ I I ' ' '• TOWN OF YARMOUTH 'f' • BUILDING DEPARTMENT • CONSTRUCTION SUPERVISOR FORM • Y • - - PLEASE PRINT: • P • - • • `JOB LOCATION: _ tv AMOS itD tU o-rjFN NUMBER . STREET VILLAGE \,OWNER OF PROPERTY: '770 DD.c o Ni a \ CONSTRUCTION SUPERVISOR 4E- . iiaytr3oa• 0D �RbQuc� 017C7 3C -- e.,0— � LICENSE NO. PHONE NO. ,ADDRESS: 1'7 n ' Creteff— • t r t,l• 26 ' ' • �"'CH C IM 4 . .. LICENSED\\ DESIGNEE: , (IF OTHER.THAN SUPERVISOR) NAMELICENSE 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 COMII•SONWEALTH, 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".OLITION 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 IY2:1EDIATELY 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 .ICENSING CC:I- STRUCTION SUPERVISORS IN ACCORDANCE WITH 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 OFFICIAL. - INSURANCE COVERAGE: - _ . ...-.. - • �` t "� ' \ I have a torr t " :lily insurance policy or ds substantial equivalent which meets the requrentents of MGL`th.152 :'.-- ' . • Yes No ❑ - . -.., .- .. _ If you have checked`vsplease indicate the,'pe c average by checking the ap;cpriate box. .- v. A liability insurance pc:icy�. crier type of :.idemnity 0 - . eond 0 ....!..:.-........12.Z. ' OWNE ' I .URANCE WAIVER:1 am aware that the licensee die! rot hive the insurance coverage required by Capt 152 .I the Mass. General L•' , and t t '' ' y signature on trs permit tcp.ic-:ion waives this requirement . . • �. �� /- • Check one: // S.gna.ifir Cener cr Goners Agent /.1 Owner Age,t!CJ / _ ' \SIGNATURE: BUILDING OFFICIAL APPROVAL: • • COMMONWEALTH OF MASSACHUSETTS v1/4 _ E=�'` - --- DEPARTMENT OF LNDUSTRIAL"ACCIDENTS _ - cd' 600 WASHINGTON STREET James J Camooeu BOSTON, MASSACHUSETTS 02111 • comm ss ones WORKERS' COMPENSATION INSURANCE AFFIDAVIT • • • 1, l /fv rcetz,4i 4 i!%!/ 1 ' . (licensee/perminee) • with a principal place of business/residence ar. /a o C-r/tEleir (;J sign/ S, a tvAir5, P7I n -d (City/State/Zip) do hereby certify, under the pains and penal.4ies of perjury,that: XI am an employer providing the following workers' compensation coverage for my employees working on this job. Cd 369Copa CAA' • Insurance Company Policy Number [ ) I am a sole proprietor and have no one working for me. [ ) I am a sole proprietor, general contraaor or homeowner (circle one) and have hired the contractors listed below who have the following workers' compensation insurance policies: = • - • - - -- Name of Contractor Insuance 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. NOTL.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 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 consisd'ng 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 mee. /�/ - ' VCT /� Signe is C O" day of , 19 73 Atir 721C0a4,4 "see/Permit-ter; Licensor/Permi;,or Nit' • 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 MGL c.142A requires that the"reconstruction,alteration.renovation.repair,modernization,conversion.inprovement,removal.demolition. or construction of an addition to any pre-existing owner-occupied building containing at least one hut 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. /7-7/0/ ' ,,/ Type of Work: (7c o s/7.7/ 1 Ch N Est. Cost 4900. Address of Work St AnUS /G(/ Owner Name: Tho Drs f n O,.)C Date of Permit Application: --//) -53 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 X'COwner 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 th gent of the owner: /0'/0'93 /11,2"S� /0937 (71 Date Contractor Name Registration No. OR: • Notwithstanding the above notice, I hereby apply for a per it as the owner of the above property: I0— I0- 93 0 14vrottnt_ I # A/44.v1.4—e- Date Owner Name