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Home My WebLink AboutBLD-93-812 + ! r . • nr of'Y`j ak Z/�z�.3 l jos. ' ' ' TOWN OF YARMOUTH T O _ 1, y. MA 'r Application for a Permit to Build No. g`i �4AT�Ta ,,s�-' UPON FINAL APPROVAL �j to °C'2- /3 MAP 1 1 S LOT ( 5^ 1 FEE MUST ACCOMPANY THIS APPLICATION. DATE OL r" `)- 2- 19 9.� L. The undersigned hereby applies for a permit to build 114/9-2M3 according to the following specifications 1. Name of property owner F hq- 4- 0 a/Sire t 1/V o rre 14, Tel. 1 `r Address (( D/ 6( 5i /r / a-' c. y peir 2.Name of Architect(if any) Tel. 3. Name of builder 6 i I I fen r e l Address h-/ S e.rvv4 cr f a 4. License No. O d D '}. 5 d Tel. r.. a l-sy9 e 5. Name of Mason Address 16. License No. Tel. 7. Construction address Il o d.d $ .t17" 16 n e Y Pal r FloodDistrict 8. Date of subdivision Approval plain zone C- Zone /_�v 9. Private dwelling 0 Estimated CostDO NSH WRITE IN THIS SPACE 10. Multi family 0 1 0D p 5 t/P lc' C�izc -or' Type of room No. POP/tot- 4wr/DC1or" l y t,4!}*! It / 11. Commercial ❑ • -Kitchen 12. Other 'R S 1r ;0 t metol- F..-o,rrot Dining Rm. 13. No. of stories Living Rm. erBed Rm. 14. Foundation — Full 0 Half 0 Crawl 0 Slab ❑ �si at 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 la Swimming pool - Size Garage 19. Storage shed — Size Shed 20. Stove — Wood ❑ Coal ❑ 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 2a 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 ' /1/ 4/vn. ,) (. L PLANNING BOARD Address I ') l 5 erLe.-4 e7 4 0 Date - y. ,D/rrr ✓}, d O2_62c COMMONWEALTH OF MASSACHUSETTS a @ . • DEPARTMENT OF Lr1DUSTRIAL ACCIDENTS 600 WASHINGTON STREET amen GammenBOSTON, MASSACHUSETTS 02111 • Cornm:ssconer WORKERS' COMPENSATION INSURANCE AFFIDAVIT • • I, lit' J l l ant ro -1 (I icensee/permi flee) • with a principal place of business/residence at er ll' a Y. P4 'li9 �/ (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. �1 b &' rN bivrc' / • Insurance Company Policy Number [) I am 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 • - who have the following workers' compensation insurance policies: •• ._- • . . . Name of Contractor Insurance Company/Policy Number.. . . Name of Contractor - • Insurance Company/Policy Number •Name of Contractor Insurance Company/Policy Number . _ • 0 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 unit, in which the homeowner also resides or on the grounds appurtenant thereto are not generally considered to be employers under the Worken'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 fa lure to iecure 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 2. 2- day of 'OL , 19 93 /Y �m • ? nen-17^ Licensee!Permittee' Licensor/Permit-tor TOWN OF YARMOUTH • BUILDING DEPARTMENT . CONSTRUCTION SUPERVISOR FORM PLEASE PRINT: . . / / / Q 1 r---- j�� JOB LOCATION: .II ' • U/G( S I/ ( T ! NUMBER . •' • . . STREET . . VILLAGE •. ' OWNER OF PROPERTY: - r.;-it. ^z yrs wave'// CONSTRUCTION SUPERVISOR: • IA.,/ / I/ O h. 1"r1 Ed •' ' OM L {d • �� 7/ NAPLE LICENSE NO. . P/HOVE NO. . . ADDRESS: 1 1 • � 'e r� ze,"1 e-4 t. /� /0 -'!p.e-r- '-�d a 1-1.-9. S� LICENSED DESIGNEE:.. Y' [� . (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 LAtS OF THE ' COtR•SONVEALTH, 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 SEECTION OF THESE RULES AND REGULATIONS AND ANY PROCEDURES, AS AMENDED, SHALL BE 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 IMMEDIATELY CEASE UNTIL A SUCCESSOR LICENSE HOLDER IS SUBSIITUTED . • • ON THE RECORDS OF THE BUILDING DEPARTMENT. ' ' : . ' .. N • - }• _ ' I HAVE READ AND UNDERSTAND MY RESPONSIBILITIES UNDER THE RULES AND REGULATIONStFOR LICENSING CC:i- STRUCTION SUPERVISORS IN ACCORDANCE :LITH 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. . . . ... .. ....Jr. INSURANCE COVERAGE: , . • ._ . : :: .. .. - .' i ....Y. -.,_ :. I have a curt nt liability insurance policy its substantial equivalent which meets the requ re:,ents of M -" : GLtth.152. '. `' • : i :'. _ ::.-' No ❑ ... ._. .... . _. ._ _ . _._ .. .. _ ..- .". - - It you have checked Nes, please indicate the type c average by checking the ap::cpriate brs A liability insurance.pcticy Other type of :ademntty 0 --- - Gond 0 - -• _ - • • • • C'NNER'S INSURANCE WAIVER:I am aware that the acensee dcei rot have the insurance coverage required:r- C:a«ter152 of the Maas. General Laws, ano that my sigra:ure on this permit ccpticaticn waives this requirement. - Check one: �vV_✓_[- _O•wnerrl Age::0 S.>sature at Cener cr Owner�yent SIGNATURE: l'✓/ill 7 Ain BUILDING OFFICIAL APPROVAL: ti .'r . 'YEA. •: - ::•.�:".' y • - ®, • _ _ _ LOT N04 1\11 :• ' ADDRESS:( '. ` OWNERS NAME- _ : SEWAGE'PERMIT NO..:ec-521 NEW: '4, REPAIR:- • -• • DATE 'ISSUEll _ .- DATE INSTALLE • D: • 6 O ' )- -_- _ - ' • • IPISTALLERS <NAAfE:' j6e :'';4 :amu, • ,-: .c-7��.- . ->- - :INSTALLATION'OF' ..;' , �T. . : . . . • • WATER_TABLE:=:.FINAL.3NSPEGTTON' D - DRAWING. OF .INSTALLATION I a • y _ f;a,R � •'1...t.^ - - • . _. { .:1....: � �Y, . •�Y7' .:' �° to-i: t " '� - - ti{••.+ f • • • • - Thio : :� 11 m.. • Suggested Affidavit for-Home-Improvement Contractor Permit Application ' - - - - - For Office Use Only NAME OF CITY/TOWN Permit Na Date • AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application • MGL e.142Arequires that the"reconstruction,alteration.renovation.repair,modernization.conversion.inprovement,removal.demolition. or construction or an addition to any pre-existintowneroccupied buildingcontain intat least one but not more than Cour 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: re rDd 'f Est. Cost 9-11&0 Address of Work 1/ o /d d < 4�/" //T / a i • Owner Name: f n g n ( e c r/v4r Date of Permit Application: /9 — 7-- 2 3 I hereby certify that: Registration is not required for the following reason(s): _Work excluded by law _Job under $1,000 Building not owner-occupied _Owner pulling own permit _Other (specify) Notice is hereby given that: 4 OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A. Signed under penalties of perjury: I hereby apply for a permit as the agent of the owner: � 0 -12-9 2 ' /// F4 10 n3 6 Date O�j Contractor Name Registration No. OR: • � " I Notwithstanding the above notice, I hereby apply for a permit as the owner of the above property: Date Owner Name • • • • . . a • • • In accordance with the provisions of MGL c 40, S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 111, S ' 150A. The debris will be disposed of in: • An fro .,,„{ k a5ze Sy$ re < (Locttion of Facility) • • 027'dzi 7 - Signature of Permit Applimnt D eLZc3 Date