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Home My WebLink AboutBLD-93-816 di Ydfik. �/,�/t3 3 's b,. .,, .-. . TOWN O F YARM O UT H (*Feu aims "AT IGCIE 41' 37 k �,, .- Application for a Permit to Build No. UPON FINAL APPROVAL Y/� f 0 a5/MAP 3 3 LOT t/ lD I FEE MUST ACCOMPANY THIS APPLICATION. DATE _, 'Z- -? 19 9 The undersigned hereby applies for a permit to build ./0 57 2. according to the following specifications hog- Name of property owner f�w1�GS� A • S ror+ Tel.9`'Z—/ 183 Address �_o J7(J�( I Eno tU2r2 1-fR mk O/ ref 3 2.Name of Architect(if any) Tel. c3:Name of builder.". A/ : I 4 ' •ddress 7SI C //�—ST�Dit�J )20 4. License No. yU 3 UC.. Tel li 2-((''—�Q/, ' ,�''o'J 7�1, 11� N' - 5. Name of Mason 6�• Address 6.License No. Tel. Avef (.7:Construction address -20 /Zap Li}, y.�'tr``°Y' -4i Flood d District n _z �' 8. Date of subdivision Approval ' plain zone r _ Zone . 9. Private dwelling 0 Estimated Cost DO NOT WRITE IN THIS SPACE Cr/LIP- tire Type of room No. 10. Multi family 0 l 7 S fa PN-, iL ! 11. Commercial 0 Pg194-4-- j/Mr2 DC Kitchen 12. Other 0 / Dining Rm. 1 gLiving Rm. 13. No. of stories ?se. 6-6 Bed Rm. 14. Foundation — Full 0 Half ❑ 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 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 2a Distance from nearest building: Front Ft. side Ft. side Rear 24. Distance back from linelior street From rear lot line Side line /4. H.I.C.R. No. /v`7t'' 3 LOT RELEASED BY 1---Signature —7/.��u . i✓,PLA PLANNING BOARD A, dres Date COMMONWEALTH OF MASSACHUSETTS _� • t DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 WASHINGTON STREET JamesCampoei, BOSTON, MASSACHUSETTS 02111 ' • comm:ss+oner WORKERS' COMPENSATION INSURANCE AFFIDAVIT • • • -744 I, , o 1 ~ aQ (l icenseelpermittee) • with a principal place of business/residence ac • �— is IA �/- Aft = moi," 4 _ / ra, (Cl /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. insurance Company Policy Number 1 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: • • •• • .11., . Name of Contractor . Insurance Company/Policy Number.. Name of Contractor - Insurance Company/Policy Number - - - • • Name of Contractor Insurance Company/Policy Number .. . 0 1 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(CL C. 152,sect. 1(5)),application by a homeowner for a license or permit may evidence the legal trams 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 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. �p Sign d this D S (J'day of C--4,L-e---"'--- , 19 P Sr ler easee!Permittee" Li censor!Ptrmittor • • • • • 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: • iith/yYl (Location Facility) • • • Sit."1.—We Signature of Permit pliant /9 -(2-s-r93 Date • Suggestedt'Affitla'vit for Home improvement Contractor Permit Application - - For orrice Use Only NAME OF CITY/TOWN Permit No. Date AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application MGL a 142A requires that the"reconstruction,alteration.renovation.repair,modernization.conversion,inprovement,removal,demolition. or construction of an addition to any precasting 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 Type of Work: / 2. c1 .9 £4 \Q !!�� , /tiff) n � - . n /S Est. Cost • '— Address of Work P-0 /(.,(.e LJ AA-7u-e � 0 1 ra,mfin Owner Name: ,c-vtn' a i'" 514_1_ - . Date of Permit Application: I hereby certify that: Registration is not required for the following reason(s): W excluded by law ob under 51,000 _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 s the agent ofofthe owner: /a-07-5-13 �` r/ " af� 1D(16c j Date Contractor Nam Registration No. OR: • Notwithstanding the above notice, I hereby apply for a permit as the owner of the above property: Date Owner Name V TOWN OF YARMOUTH • BUILDING DEPARTMENT CONSTRUCTION SUPERVISOR FORM • • /PLEA, E!-arNx ., ,� • • . ' ' OB OCATION: D l�PI 4 CI) lI NUMBER S_t ET n �VI�LL,,AG�En WNER OF PROPERTY: • • . A .2'►!_ ' ' ;9 iiii. I�� ( L Cr'�•• ( `-o CONSTRUCTION SUPERVISOR: . t ///�1GLP�ft� 44- Lc?µNo %PH 9D,NO. C) 1.45 . SS: • • 'JJ' v S •.. ! ' - •' i/, _, Wag ' 46 + ' ' • LICENSED DESIGNEE / ( J /4-- • • • � y� (IF OTHER-THAN SUPERVISOR) NLICENSE NO. 2.15 RESPONSIBILITY OF EACH LICENSE HOLDER: • t 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 ' COPLMONWEaLTH, 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 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 I:'MEDIATELY CEASE UNTIL A SUCCESSOR LICENSE HOLDER IS SUBSTITUTED • • ' ON THE RECORDS OF THE BUILDING DEPARTFENT. ' ' . -,,r- " ' ' . • , I HAVE READ AND UNDERSTAND MY RESPONSIBILITIES UNDER THE RULES AND REGULATIONS ,FOR LICENSING CC:T- STRUCTION SUPERVISORS IN ACCORDANCE WITH SECTION 109.1.1 OF THE STATE BUILDITG CODE. I UNDERSTAN: THE CONSTRUCTION INSPECTION PROCEDURES AND THE SPECIFIC INSPECTION AS CALLED FOR BY THE BUILDING OFFICIAL. . . . .:. ..:.. .... . :. .. :. _. _ • - . i .. -- ♦ F . > I have a current liability insurance pclicy or its substantial equivalent which meets the requirerents of MGLth.152 ,',h'..;'- ':. Yes ❑ . :.. " Na ❑ If you have checked Nes, please indicate the type a:vera by'checking.the aparcpn7ate bnc • ' -' ` - - • A liability insurance pdicy 0 Cher type of ademnity 0 -•• Band 0 - - - -- .. • O'WNER'S INSURANCE WAIVER:I am aware that the licensee does' rot have the insurance cover;; requires tv C`ap;er 152 of the Mais: General Laws. ano that my signature on the permit :splication wanes this requirement . . - • . • Check one: • • , ti uwner❑ Agent 0 • . gn lire at `.net Crcr Owner s Agent iff IGNATU• - /ad ft' BUILDING OFFICIAL APPROVAL: .,