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HomeMy WebLinkAboutBLD-93-809 i'%a Tr , o TOWN OF YARMOUTH or i%v/9g "< • g' Application for a Permit to Build No. V 9 ;_- Pc' 10 -2 -11-3 �r UPON FINAL APPROVAL Li MAP 44P 7'7 LOT S2 / FEE MUST ACCOMPANY THIS APPLICATION. DATEo x/ 91.%.19- .. The undersigned hereby applies for a permit to build /o �/ ? according to the following specifications 1%.7l9.3 1. Name of property owner tE/y/9 /-' ertiA�/ Tel.;99f1 Dog, / Address eo ,6 Ae ezo GUay 5. �/�iM9'ct 7V 2.NameofArchitect(if any) / / Tel. 3. Name of builder .0GfI�E/e Address 4. License No. Tel. 5. Name of Mason Address 6. License No. Tel. 7. Construction address /0620.44.aS zZi4/ C)49,Meirtii 4$o2 6 z Flood District 8. Date of subdivision Approval plain#ne G Zone 7 7 /o'ta- DO NOT WRITE IN THIS SPACE 9. Private dwelling ] Estimated Cost �yvi�. 1 /� /p,� Type of room No. 10. Multi family 0 �' �'Qp �t�" oviH irsv/ �f < ions/13 pis- c.G('iF,n i I 11. Commercial 0 Kitchen 11- 12. Other 0 �s�m/�i'', �� S-o� Dining Rm. """7�� Living Am. 13. No. of stories V°%� - /e . �' D�+� Bed Rm. 14. Foundation — Full al Half 0 Crawl 0 Slab ❑ i Tr , a� in.. Bath 15. Materials — Wood 0 Cement 0 Other 0 Deck _ 16. Type of heat — Oil 0 Gaspf 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 line Side line 25. H.I.C.R. No. LOT RELEASED BY Signature -/J, / —2.0--/�1" PLANNING BOARD Addres ., i_ _;. it. . A Date 'c c /A ! /,!: S, ®024:7 1 TOWN OF YARMOUTH BUILDING DEPARTMENT /' HOMEOWNER LICENSE EXEMPTION PLEASE PRINT: DATE /6/09tS ����)) �Q JOB LOCATION /p0j CU 1 4g4de: t'4t 1 di, �� ER ST' rET/yADDRESSS / SECTION OF TOWN "HOMEOWNER" 'V�G'�,e,, A . �J,�.DGa1f�-// 37' D37O . 45-nt, N E HOME PHONE WORK PHONE . PRESENT MAI ING ADDRESS • 4o4acez4i �� . TY OR TOWN STATE deaZI CODE THE CURRENT EXEMPTION FOR "HOMEOWNER" WAS EXTENDED TO INCLUDE OWNER- OCCUPIED DWELLINGS OF ONE OR TWO UNITS AND TO ALLOW SUCH HOMEOWNERS TO ENGAGE AN INDIVIDUAL FOR HIRE WHO. DOES NOT POSSESS A LICENSE, PROVIDED . THAT SUCH HOMEOWNER SHALL ACT AS SUPERVISOR. (STATE' BUILDING CODE SEC- • 109.1.1) DEFINITION OF HOMEOWNER: PERSON(S) WHO OWNS A PARCEL OF LAND ON WHICH HE/SHE RESIDES OR INTENDS TO RESIDE, ON WHICH THERE IS, OR IS INTENDED TO BE, A ONE OR TWO FAMILY ATTACHE D OR DETACHED STRUCTURES ASSESSORY TO SUCH USE AND/OR FARM STRUCTURES. A- PERSON WITO CONSTRUCTS MORE THAN ONE HOME IN A TWO-YEAR PERIOD SHALL NOT BE CONSIDERED A HOMEOWNER, SUCH "HOMEOWNER" SHALL SUBMIT TO THE BUILDING OFFICIAL, ON A FORM ACCEPTABLE TO THE BUILDING OFFICIAL, THAT HE/SHE SHALL BE RESPONSIBLE FOR ALL SUCH WORK PERFORMED UNDER THE BUILDING PERMIT. (SECTION 109.1.1) THE UNDERSIGNED "HOMEOWNER" ASSUMES RESPONSIBILITY FOR COMPLIANCE WITH THE STATE BUILDING CODE AND OTHER APPLICABLE CODES, BY-LAWS, RULES AND REGU- LATIONS. THE UNDERSIGNED "HOMEOWNER" CERTIFIES THAT HE/SHE UNDERSTANDS THE TOWN OF . YARMOUTH BUILDING DEPARTMENT MINIMUM INSPECTION PROCEDURES AND REQUIRE- MENTS AND THAT HE/SHE WILL CO LY WITfi SAID PROCEDURE REQUIREMENTS. HOMEOWNER'S SIGNATURE _J4 Of APPROVAL OF BUILDING OFF • INSURANCE COVERAGE: I have a curre liability Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No ❑ If you have ecked yes. please indicate the type coverage by checking the appropriate box. A liability Insurance policy 0 Other type of Indemnity 0 Bond 0 OWNER'S INSURANCE WAWER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. • Check one: Owner 0 Agent 0 Signature of Owner or Owners Agent ` _' COMMONWEALTH OF MASSACHUSETTS _ _ . f `c - - . - DEPAIiMENTOFINDUSTRIALACCIDENTS 600 WASHINGTON STREET - . James Camvoei, BOSTON, MASSACHUSETTS 02111 • ro rm:ss once WORKERS' COMPENSATION INSURANCE AFFIDAVIT • • I.e_,E� JJ L , Au )E-7/ (licensee/pe mee) • with a principal place of business/residence at • to •. P©0 /401) .�f1AA42/ 1 , ,4e , ( (Ciry/Sure/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 [ ) I am a sole proprietor and have no one working for me. [ ) I am a sole proprietor, general contractor o • • •rde one) and have hired the contractors listed below who have the following workers' compensation insurance policies: ••.--,-----4--, • • -•- -r • - - - - • - Name of Contractor . . Insurance Company/Policy Number.. . . • Name of Contractor • Insurance Company/Policy Number • - Name of Contractor Insurance Company/Policy Number . - 2 I am a homeowner performing all the work myself. - NOTE.Pleue 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 arc not generally considered to be employers under the Workers' Compensation An(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 lnsurance for coverage verification and that failure to s'ccure coverage as required under Section 25A'of MGL 152 can lead to clic 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 S100.00 a day against me. Signed this day of , 19 1 cr." S �.1 /. , . ! (4!'#t� i// =sc.' ermirec' LicensoriPermirtor Suggested Affidavit for Home Improvement Contractor Permit Application . • For Office Use Only NAME OF CITY/TOWN Permit No. Date i . AINIUAVIT - Home Improvement Contractor Law Supplement to Permit Application MGL e.142A requires that the"reconstruction.alteration.renovation.repair,modernization,conversion.inprovement,removal.demolition. or construction of an addition to any pre-existing owner-occupied budding containingat least one hut 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. Type of Work:S//67 (Y4A2X'e y ,� " ''���Q Est.sCost /679 c9/� Address of Work of /�� /5�f}RRPCO y / J£ ki ou77 Mit, C2Uc/ • Owner Name: (CERA>,/ / . t c�a,� iel / \ Date of Permit Application: /0/ /P. • \ 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: Date Contractor Name Registration No. . OR: • Notwithstanding the above notice, I hereby apply for a permit as e owner of the above property: ie Owncaeg me BUILD RM APPLICANT: , /&' �' / BUILDING PERMIT 1/: ADDRESS: .41I iI i Zli� Vo E. NO. : DATE FILED: • BLDG. SITE LOCATION: ` MAP//: LOT/i: THE FOLLOWING INFORMATION OUTLINES THE PROCEDURAL STEPS REQUIRED TO OBTAIN A PERMIT TO BUILD, ALTER, OR ADD TO A STRUCTURE WITHIN THE TOWN OF YARMOUTH. THE BUILDING DEPARTMENT WILL DETER- MINE COMPLIANCE TO THE FOLLOWING (A) ZONING REQUIREMENTS (B) HISTORICAL DISTRICTS (C) FLOOD PLAINS ZONING. THE BUILDING DEPARTMENT WILL BE RESPONSIBLE FOR ASSISTING THE APPLICANT THOUGH THE FOLLOWING DEPARTMENTS: RESIDENTIAL AND/OR COMMERCIAL BUILDING WATER DEPARTMENT: DETERMINES COMPLIANCE OF WATER AVAILABILITY. • ENGINEERING DEPARTMENT: DETERMINES COMPLIANCE FOR PARKING AND DRAINAGE. CONSERVATION COMMISSION: DETERMINES COMPLIANCE TO WETLANDS ACTS, I.E. : IF LOT(S) BORDER ANY TYPE OF WETLANDS, STREAMS, PONDS, RIVERS, OCEANS, BOGS, BAYS, MARSH LAND, ETC. HEALTH DEPARTMENT: DETERMINES COMPLIANCE TO STATE AND TOWN REGULATIONS, I.E. : REQUIRE- MENTS FOR SEPTAGE DISPOSAL AND OTHER PUBLIC HEALTH ACTIVITIES. FIRE DEPARTMENT: DETERMINES COMPLIANCE TO STATE AND TOWN REQUIREMENTS FOR PERSONAL SAFETY, PROPERTY PROTECTION, I.E. , SMOKE DETECTORS, SPRINKLER SYSTEMS, ETC. THE FOLLOWING DEPARTMENTS MUST SIGN OFF, IN THE RESPECTIVE ORDER, PRIOR TO BUILDING INSPECTOR ISSUING THE REQUIRED BUILDING PERMIT: REVIEWED BY: 1. WATER DEPARTMENT DATE: N/A: 2. ENGINEERING DEPARTMENT: DATE: N/A: • 3. CONSERVATION: DATE: N/A: 4. HEALTH DEPARTMENT DATE: N/A: INDUSTRIAL AND/OR COMMERCIAL PERMITS 5. WIRING INSPECTOR: DATE: N/A: 6. PLUMBING INSPECTOR: DATE: N/A: 7. FIRE DEPARTMENT: DATE: N/A: • PLEASE NOTE ALL STUMPS AND/OR BRUSH MUST BE DISPOSED OF AT AN APPROVED SITE. A SIGNED RECEIPT FROM THE DISPOSAL SITE MUST BE SUBMITTED TO THE BUILDING DEPARTMENT PRIOR TO ISSUANCE OF THE BUILDING PERMIT. �J CO: NTS: iE Z.4 ',knee-4e a5 1'r/�SIO!'iL ,t )t C,)/AZ a) /Pre- Ori 'Orrin - lyli a/� ) erH Qr.htrooe .31 b� foi2- k>ooD 6'2 CO)fl 5•1/2 02 FvrLwist-c a� PirArt, C, ,Limit Cy/Mgt !in- 3 ' 01%l t- �k'i ba-ds cit .2 Oren- /O' Our- . / / de • 1q3 6OI 2�