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Home My WebLink AboutBLD-93-825 i . ` "_ o i TOWN OF YARMOUTH or-144k4- ,. ; MATTACME 5 ` •• ti ,� �s,ce i , Application for a Permit to Build No. fiaS 3 UPON FINAL APPROVAL O MAP %/ ¢{ LOT ie / FEE MUST ACCOMPANY THIS APPLICATION. DATE .25- 10 93 The undersigned hereby applies for a permit to build /d/26/93 according to the following specifications /6 3'6793 1. Name of property owner /eon ad F iA Pr Tel.3601— Address C24 Main Sf' /areN evA--Ap o-f Fa Cr 2.Name of Architect(if any) Tel. a Name.of builder (Aeries 71/44€boo Address av3 /JnianSit y►iwcrthper/- 4. License No. 61/4/3-3 9 Tel. ' 36 2— YO 32 /hn 5. Name of Mason Address 6. License No. - Tel. frei . , n/ 7. Construction address i ..24 -1a7 Y&rnn oa/Ap�fJ fila • A 6 4 Flood District •L - a 8. Date of subdivision Approval plain zone G Zone ' 9. Private dwelling 12( - Estimated Cost DO NOT WRITE IN THIS SPACE ST/Z1 p_ Reim f Type of room No. 10. Multi family ❑Si,P a 73-0• D O • r,�� 11. Commercial 0 Pat is I it too f- aprox is" POP. Ver To Kitchen 'I ce/a- 614ck `o 1;atch emh C- 12. Other 0 �9�v� Dining Rm. a vf-roet 13. No. of stories p �od� Living Rm. Bed Rm. 14. Foundation — Full 0 Half Q Crawl 0 Slab ❑ (6( Bed , CT Bath 15. Materials — Wood 0 Cement 0 Other 0 Deck 16.Type of heat — Oil 0 Gas 0 Electric 0 Other 0 Closed porch Family Rm. 17. Garage — 1 0 2 0 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. //V7/ 8 :LOT RELEASED BY Signature -' I Z . ..- PLANNING PLANNING BOARD Address Pa 3 //nnv 7 Date 14frinv A 0x675' Suggested Affidavit for Home Improvement Contractor Permit Application. - - . For Office Use Only NAME OF CITY/TOWN Permit No. --- („YQr Yh D GL Date AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application MGL c.142A requires that the"reconstruction,alteration.renovation.repair,modernization,conversion,inprovement,removal.demolition, orconstruction of an addition to anv pre eiisting owner-occupied buildingcontaining at 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 aceptions,along with other requirements. � Type of Work: PP rocI — fai-Pin I -/C)9.. / 'f Est. Cost .2 ,SO.Co Address of Work cS �( iam S7_ y/-/x0LL/Yifci /41/�4 Owner Name: /lee r7ok1c . )625 1- ' Date of Permit Application: Orj ?. /Q 9 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 the agent of the owner: 0(f PCAlf 3 e z? AlaPO //97/69 Date `ct``ntractorNammee Registration No. • OR: CJ73 Notwithstanding the above notice, I hereby apply for a permit as the owner of the above property: Date Owner Name • • _I COMMONWEALTH OF MASSACHUSETTS ' , A • DEFARTMEN'T OF LNDUSTRIAL ACCIDENTS r' 600 WASHINGTON STREET • James Campbell BOSTON, MASSACHUSETTS 02111 • • Commrssioner WORKERS' COMPENSATION INSURANCE AFFIDAVIT • • Cliai-/ec ' Mel it, (licensee/permittee) • with a principal place of business/residence an • `+J 3 anion S& �ai-nn r/A./42c/$ /�Q- 0? C// Vr" (City/ tate/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 114/1 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: ,-. Name of Contractor Insurance Company/Policy Number ... . Name of Contractor Insurance Company/Policy Number . . _ .. .. • Name of Contractor Insurance Company/Policy Number .. : - 1 am a homeowner performing all the work myself. NOTL_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 lnsuranci for overage verification and that failure to&cure 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 ‘.5—j day of Or";4DA4v , 19 93 4 - 'i - Licensee;Permittee Licensor/Permit:or TOWN OF YARMOUTH BUILDING DEPARTMENT . ' CONSTRUCTION SUPERVISOR FORM ' PLEASE PRINT:! ' ' . . �^ . /- • JOB LOCATION: 4'2.4 Kinn i 1,, J /- �o_fr m f DYT NUMBER STREET VILLAGE / . ' .OWNER OF PROPERTY: ' 1pn ,:,,a .� . A,.Figr? . • • CONSTRUCTION SUPERVISOR: , • r r i-kg if'�Au rn •'Q'4/a.<39 . 34a; 3P2 NAME i• // . LLICENN�S�• JE NO. �, PHONE NO. • . ADDRESS: "go 3• •'/..iAm i $'i 161IN1Oit? . /�O�`T - /�� ogc7J • '" 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 ' COILMONWEALTH, 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 LMMEDIATELY CEASE UNTIL A SUCCESSOR LICENSE HOLDER IS SUBSTITUTED ' ' ON THE RECORDS OF THE BUILDING DEPART.ENT. - ' • . ' . • I HAVE READ AND UNDERSTAND MY RESPONSIBILITIES UNDER THE RULES AND REGULATIONS ,FOR :SCENSING CC} 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. . ;. . ..• : ., • • • ,.._ . . . INSUAANC'c COVEAAC'c: I have aces eg,liability insurance policy or its substantial equivalent which mee!s the require rents of M3L1lrh.152 s' '- . . i!e _ ._r If you have checked ves• please indicate the type coverage by checking the ap:rcpriate bcx "'=- -' e `0: . liabilityA _ i. _ . insurance pc.rty � Other type of:.idemnity 0 ••• Band p - -- - - OWNER'S INSURANCE WAIVER: I am aware that the licensee does rot have the insurance coverge'requirec`y •- Chapter 152 of the Mass: General Lws. ana that my signature cn this permit :cp:ic:Pon wares this requirement ' • . • • Check one: • • Owner" Agent 0 ' Signature of Owner cr Owner s Agent . SIGNATURE: K.ai.jUn (9,_•,�,1.TT- BUILDING OFFICIAL APPROVAL: 1/4E