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$4.- : o ,a, TOWN OF YARMOUTH
,,"L.ATo Y J Application for a Permit to Build No. i-3
UPON FINAL APPROVAL P. /0--';°'-)AAP 16 LOT ii.-14/9
FEE MUST ACCOMPANY THIS APPLICATION. DATE /0 /z5--19 ?3
The undersigned hereby applies for a permit to build /x9079'5
ording to the following specificat.!ops
1. Name of property owner /C ya & S tt/g 5c%" Teta/7 85"7.2. -
Address M /2� .5-_ /-✓, 2',,,z-.Artavzrr
3/Name of Architect(if any) Tel.
3. Name of builder_ Address
4. License No. Tel.
5. Name of Mason _ Address
6, !cense No. Tel.
Construction address to gm-k- S. In! , z. a ti-rhe
i
Flood District if-24--
8. Date of subdivision Approval plain zone Zone
9. Private dwelling 0 Estimated Cost DO NOT WRITE IN THIS SPACE
Type of room No.
10. Multi family 0 = ,j�"25 / —
11. Commercial 0 "eitel et-ct /GL' -d-ra-C) Kitchen
12. Other ❑ �dI° � c Dining Rm.
'3S' �"�
13. No. oIf stories -/-X 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 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 _
PLANNING BOARD Address /o M4-, Sr.
Date //, y47.4_Ko.., -2-c!
t I
TOWN OF YARMOUTH
BUILDING DEPARTMENT
► HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
DATE IOh—V S
JOB LOCATION 10 / t 5Tf i-f4ar,
BER STREET ADDRESS SECTION OF TOWN
"HOMEOWNER" Vi 67" 0/2 1/,1,,30,) 6/7 950' 7-WC
NAME HOME PHONE WORK PHONE
PRESENT MAILING ADDRESS /lilt n--"P
CITY OR TOWN STATE ZIP 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
ATTACHED OR DETACHED STRUCTURES ASSESSORY TO SUCH USE AND/OR FARM
STRUCTURES: A. PERSON WHO 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 COMPLYAWITH SAID PROCEDURES AND REQUIREMENTS.
HOMEOWNER'S SIGNATURE !/S/ , `� _r,
APPROVAL OF BUILDING OFFICIAL
INSURANCE COVERAGE:
I have a current liability Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes ❑ No ❑
If you have checked es, 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 WAIVER: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 at Owner cr Owner s Anent
PLOT PLAN
•
FOR LOT it •
• Indicate location of garage or accessory building
Additions with dashed lines .
Sewerage disposal (cesspool)
• Well 0
I (lot ft. rear)
Abuttor I s I Abut
Name I Name
Lot # • 1 • Lot ;r
REAR YARD
If this is a • 2 If t
corner lot, 1 ft. corn
write in name writ
I name
of street. b
• o . othe
4C7 ,, v sire
co
N •
.
•
•
SIDE YARD SIDE YARD '
•
•
_ _ FT_ r'� HOUSE 0 2-7
/ FT
•
Q4 .
• • 1
•
A • I •
SET p�BACK •
• ` a ft.
•
o
. . . • I
__- 1
1
.
(lot PI° ft. frontage)
•
\ / P,�2K s-p . .
\ / (NAME OF STREET) •
• % ' . • •
\
-Information •
\ Supplied by
•
•
•
_= ` COMMONWEALTH OF MASSACHUSETTS
`tet • DErARTMEN'T OF LNTDUSTRIAL ACCIDENTS
600 WASHINGTON STREET
tames GamDDel; BOSTON, MASSACHUSETTS 02111 •
commissioner WORKERS' COMPENSATION INSURANCE AFFIDAVIT •
C 3 w✓
(I i censee/permittee)
• with a principal place of business/residence an
•
(City/Sute/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
Krfrrn 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: •-t...• ..-• ••.
Name of Contractor Insurance Company/Policy Number
Name of Contractor - • Insurance Company/Policy Number
• •Name of Contractor Insurance Company/Policy Number . " •
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 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
consisting of a fine of up to SI 500.00 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 ®e , 19 "3
Licensee/Permitter' LicensoriPermiaor
Suggested Affi'dairit 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
MGLc.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 but 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: /-1rZ9ti fe cce —L j i 5 at. Cost .560 —
Address of Work oto Si-kr S'i L✓. 4'a I- o rev
�(
Owner Name: C '-e1)1 •
�L✓el
Date of Permit Application: /0/2VA3
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 •
4 Cwner 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 .4 .
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 the owner of the above property:
)
Date Owner Name