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Home My WebLink AboutBLD-93-817 O1..YA4 /�/$� $ s - TOWN OF YARMOUTH c �' ` MATGCM EES+4' • 8/ / �,,c-ac:::::','"):.- Application for a Permit to Build No. Ta I UPON FINAL APPROVAL fJ I MAP 3 6 LOT ll FEE MUST ACCOMPANY THIS APPLICATION. DATE /0'02r 19 93 The undersigned hereby applies for a permit to build 744. 4'.3 accoorrdjng to the following specifications 4� Whams of property owner �,c( lvlr/�Tcag Tel. Address 2.Name of Architect(if any) Tel. l3:Name of builderLE/(^ 13CC Address E304, C oUCOCr'u RD 4. License No. 1(1 5-5 a Tel. 290 -fYS—gr 5. Name of Mason _ Address 6. Li ense No. Tel. - . Construction address SC 3ioflf ST &a cishe/s'16u— Flood District 8. Date of subdivision Approval plain zone Zone nS-as 9. Private dwelling ❑ Estimated Cost DO NOT WRITE IN THIS SPACE 10. Multi family 0 f t''G , $r,&P- i Qge r F Type of room No. Peips- l/i vr� ate (cPAnt- 11. Commercial 0 r —Kitchen _ 12. Other ❑ /: 3C Dining Rm. Living Rm. 13. No. of stories Bed Rm. 14. Foundation — Full 0 Half 0 Crawl 0 Slab 0 0r Crti 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 23. Distance from nearest building: Front Ft. side Ft. side Rear 244..Distance back from line or street From ar t line Side line 5. H.I.C.R. No., /1/ S 90 X:::=, LOT RELEASED BY ( ignature ' PLANNING BOARD Address 30 C/ OCA-1 ea. Date frkrtt?NOrS MR_ 00 CC( 111 1 . TOWN OF YARMOUTH • BUILDING DEPARTMENT CONSTRUCTION SUPERVISOR FORM " PLEASE PRINT: ;. • • ' JOB LOCATION: •�� SOU� I. �) / • C U . /& / MI ' ' OWNER OF PROPERTY/jcj ' •�Jils( /�S STREET. / VIL GE CONSTRUCTION SUPERVISOR: C r7/c r? ( /L3 46X '�t l .a c ' NAME LICENSE NO. PHONE NO. , . ADDRESS: • • • - LICENSED DESIGNEE:.' ' - , ' (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 LAWS OF THE COhQMONWEALTH, 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:L*'.EDIATELY CEASE UNTIL A SUCCESSOR LICENSE HOLDER IS SUBSTITUTED ON THE RECORDS OF THE BUILDING DEPARTMENT. ' • . .. '1 . I HAVE READ AND UNDERSTAND MY RESPONSIBILITIES UNDER THE RULES AND REGULATIONS .FOR LICENSING CC:1- 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. . 1 '1: _ . . .. . _ •1.-... -.,- INSURANCE COVERAGE: •' . I have current aiability insurance pclicyemen or its substantial equivalent which meets the requirts of MGL�h-152 ;:'.'.'-::—. '.;'. . :Yes ❑ No ❑ •..;:.-:...- -.:- '.. �. . ' If you have checked vet, please indicate the type c average by checking the apgrcpriate bc:c _ ,`' .•- • ' . A liability insurance pc:icy 0 7 O:her type of :.idemnity❑ -•• e.and 0 -'-'-_-`� _ , OWNER'S INSURANCE WAIVER: I am aware that the ucensee des not have the insurance coverage required v C.. ter 152 of the Mass: General Laws• ana that my signature on the permit acplicaticn waves this requirement ' • Check one: • ' _Ownerp .Agent❑ • Signature of Cl.ner O • .�ne� ye, SIGNATUR / .1EU LDING OFFICIAL APPROVAL: Suggested Affidavit for Home Improvement Contractor Permit Application • Fel Office Use Only NAME OF CITY/TOWN Permit No. . Dale AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application MGL c.142A requires that the"reconstruction,alteration.renovation.repair,modernization.conversion,in provement,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. ,�,p��^-^pp,�,�� (COO —CO of Work: e (J,- Est. Cost l tt)_t O Address of Work 35- sewn/ 577 Scum( "-Mteloarli Owner Name: vac /1WIQ&''FC • Date of Permit Application: !b p2S73 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 _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 e a h., the owner: -c9 / - fllr, Date entractor Name Registration No. OR: • Notwithstanding the above notice, I hereby apply for a permit as the owner of the above property: Date Owner Name �__` _ COMMONWEALTH OF MASSACHUSETTS e =_ C th‘ - @ DEPARTMENT MENT OF INDUSTRIAL ACCIDENTS " . 600 WASHINGTON STREET • James J CampbellBOSTON, MASSACHUSE. U, 02111 Lomm:ss over WORKERS' COMPENSATION INSURANCE AFFIDAVIT • I, 7. /r--/f` ( C iC (licensee/perminee) • with a principal place of business/residence an • 30C C(6)Ca(/1) f6rf-D f AJ/00 fl4' 'Q9° ( (City/State/ p) 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 11-t<in 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: - (er•, eee Name of ContactorInsurance Compan 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. 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(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. 1 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 iccure coverage as required under Section 25A'of MGL 152 can lead to the imposition of criminal penalties • consisting of a fine of up o/1500.00 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 n Signed this / / day of LC/�A/ OCA , 19 92 LicenseeiPermirec' Licensor/Permitror • • • • • • • 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 MOL c 111, S • 150A. The debris will be disposed of in: • riaCjc5!-(Location of Facer I y�en)07A ility) • • • ► / /Alt S'gnature of Permit Applicant Date • • • . • •..: ,... ..