HomeMy WebLinkAboutBLD-93-836 '' , ,'� TOWN OF YARMOUTH O�1�,3
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N :ATTACHE 5_ '., Application for a Permit to Build No. a%
P"''�m.,,,..`��d'%
UPON FINAL APPROVAL )U or2, 1e)3 MAP S0 LOT 7/8 7
FEE MUST ACCOMPANY THIS APPLICATION. DATE Oa+ a17 19
The undersigned hereby applies for a permit to build /o/ 9� --3
according to the following specifications /%/Ina
1. Name of property owner my-, + Mkt, Pcww 0pfo N Tel.7(o -3X5)
Address 33 t-Rectr,1-,o.. Col Sea Vci....n..
2.Name of Architect(if any) t Tel.
3. Name of builder BM Kr nos key Address
4. License No. Tel. 3(`1 ' - 7.2.7 7 T HERl OD
7-D I IUNTINGTON AV2.
5. Name of Mason Address SOUTH ,,1 n",,n,'ITH MA Q2RF4
6. License No. Tel. ' /
7. Construction address 3 3 R &L -t1'Op" 4" Si-alt, ri oa
FloodDistrict R,_yo
8. Date of subdivision Approval plain zone c Zone
9. Private dwelling 0 Estimated Cost DO NOT WRITE IN THIS SPACE
Type of room No.
10. Multi family 0 3 a'
000, Rrrl� /
11. Commercial 0 S 4-h io 4-.1-e roe& a a("%
• •' BUILDING DEPARTMENT . . .
• CONSTRUCTION SUPERVISOR FORM : ' ' .
r .
PLEASE PRINT: ' .
•
• JOB LOCATION: ,LA . %,...,ec {e. 40.0n) w� � ri�aH'T� •
NUMBER 11 l L• STREET VILLAGE -
OWNER OF PROPERTY: • �.,, h Mw, HewKt `Jr\0�1 _
CONSTRUCTION SUPERVISOR: Bill' ( r C.IJ S C.e10,35 �(, .326-72.-77.
• NAME 7 . . ' LICENSE NO. . PHONE NO. ' .
ADDRESS: THEF�11i10 :
7-D HUfvTfNG f uiN AVT:.
LICENSED DESIGNEE: SOUTH YARMOUTH, MA 02664
(IF OTHER THAN SUPERVISOR) NAME LICENSE NO.
2.15 RESPONSIBILITY OF EACH LICENSE HOLDER:
• ' :::.‘1..:L% :.,.: rMill )YEMEHT
.. . i. ,ton Aoeoue
is
2.15.1 THE LICENSE HOLDER SHALL BE FULLY AND COMPLETELY RESPONSIBLEFOR ALL WORK FOR,WHICH HE
IS SUPERVISING. HE SHALL BE RESPONSIBLE FOR SEEING THAT ALL WORK IS DONE 'PURSUANT TO THE STAT
BUILDING CODE AND THE DRAWINGS AS APPROVED BY THE BUILDING OFFICIAL
2.:5.2 THE LICENSE HOLDER SHALL BE RESPONSIBLE TO SUPERVISE THE CONSTRUCTION, '..RECONSTRUCTION,
ALTERATION. REPAIR. REMOVAL OR DE`!OI,ITION INVOLVING THE STRUCTURAL ELEMENTS OF BUILDING
AND STRUCTURES ONLY PURSUANT TO THE STATE BUILDING CODE AND• ALL OTHER APPLICABLE LAWS OF THE. .
CC:•2•1ONWEALTH, EVEN THOUGH HE, THE LICENSE HOLDER, IS NOT THE PERMIT HOLDER BUT ONLY A SUB-
CCNTRACTOR OR CONTRACTOR TO THE PERMIT HOLDER.
2.:5. 3 THE LICENSE HOLDER SHALL L"_•!EDIATELY NOTIFY THE BUILDING OFFICIAL IN WRITING OF THE
•
DISCOVERY OF ANY VIOL;TIONS ''WHICH ARE COVERED BY THE BUILDING PERMIT.
2.:5.5 ANY LICENSEE WRO 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 3E SUBJECT
TO REVOCATION OR SUSPENSION OF LICENSE BY THE BOARD.
.:5. ALL BUILDING PERMIT APPLICATIONS SHALL CONTAIN THE NAME. SIGNATURE AND LICENSEE NUMBER^O`
:HE 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
CCI'z AND THESE RULES AND REGULATIONS. IN THE EVENT THAT SUCH LICENSEE IS NO LONGER SUPERVISi:
SAID PERSONS. THE WORK SHALL IrEDIATELY CEASE UNTIL A SUCCESSOR LICENSEE HOLDER IS SUBSTITUTE:
ON 1 E RECORDS OF THE BUILDING DEPARTMENT.
I HAVE READ AND UNDERSTAND MY RESPONSIBILITIES UNDER THE RULES AND REGULATIONS .FOR LICENSING
S- _-:ON SUPE V EC:IO -
+:•-�• ISCRS ::; ACCORDANCE WITH S :; 109.1.1 0: THE STAT:. 3UILDI:;C CODE. I U:;DERS:
THE CONSTRUCTION I::S:c:.._ON ?RCC`:.UR_S AND THE SPECIFIC INSPECTION AS CALLED fOR B:' THE •BUILD'
OFFICIAL. • _ '
INSURANCE CCVERACc:
I have a e:..rc s'.addity ins;::anc •
^ Fc:ic- cr s etr--_.sz ec_:ratent v n
It Yes No0 c- ...._.. . e .eyt:rer-:rtsef :.t3�Z.y,152
you have _.._cked • ;e..^ _
^_• inc::..._ :.. :;,,: .:•:er_6e by cnecx6•tq ::._ _::::::Iia:e h
cs,
A IiaCility insurance C..i:�
^. Cher type cf 'Acemnay 0 ecnc 0
C'NNEF': :NSCR.:.::c.: ',v:..: .7.......
C: •
_:. •l c . .... ... C..:• L'.vs. . - •..�' -� _ — .. ..._ c e::;: rec ::e:
.. S -._.- .... _.... . .::..: .: .,v,z.ves r:z tc de:-
MIC •r . 4..j-t -r*... e, . _::%17.:: �- `1 {:. .; , ...._
Y .t.
•
' Suggested Afridavit,for Home improvement Contractor Permit Application
• • Poi.Office Use only NAM OF CITYITOWN • .
4
Permit N> Yom.111001k •
3
..Dale
•
t /DAVIT
AF .
Home Improvement Contractor Law • • . .
Supplement to Permit Application
MGLc.142A requires that thereconstruction,a Itention.renovation.repair.modernization,conversion,inorovement,removal.demolition,
ereonstruction of an addition to any prccelstine owner-occupied building containioeat least one but not more than fourdwtlline unils...,or
•l0 structures which are adjacent to such residence o+ buildine"be done by registered contractors,with certain exceptions,along with other. • '
requirements. �1 ��
Type of Work: c II; a 1-e F.00 "— INSv�+G .vJtt E caIL. Est. Cost"3 000.00 • ,
H• .Address of Work 83 t�-(ee4,i,. alt CYa alk IAksion k • ••
• Owner Name: 'i'i4 tr. o.r..e 1+6..
Date of Permit Application: /V— .27(—93 , • . • r,
I hereby certify that:
Registration is not required (or the following reason(s):
' _Work excluded by law • ,j .
_Job under 51,000 • , '
_Building not owner•occupicd '
' _Owner pulling own permit •
_Other (specify) _ .
•
Notice,Is hereby given that: — •
i
• ' ' • OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH-UNREGISTERED" t •• • ..
CONTRACfORSFOR APPLICABLE HOME IMPROVEMENT WORK DONOTHAVE • •r •
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:
•
• /o-a7-93 1111 Med vtkey c _4053.9.210_______
Date Contractor Narle
\\ tQ Registration No.
OR: ,
Notwithstanding the above notice, I hereby apply for a permit as the owner of the above property:
•
•
Dale Owner Name . .
i;:rci.: h#JL: iui?aQ' .coli t,,...
1ptf {MPNfivEMENT {flC,
;t... i ftillt:+l ltii't .R4'S+Si;ti ,
. it.;rs+.i:.:41„ lxva ..3titIw , „•„�„ 'out. "'Whit;
THIS1 c'7MLico •
!a-O HU TLSGTCN AVE. •
SOUTH YARMOUTH,MA 02664
.
•
• A COMMONWF.AT.TH OF MASSACHUSETTS
• DEPATC MENT OF INDUSTRIAL ACCIDENTS
' 600 WASHINGTON STREET • •
as Campbell •. BOSTON, MASSACHUSETTS 02111
ommss+oner
•
WORKERS' COMPENSATION INSURANCE AFFIDAVIT
•
I, THERs'NCO, ' INC
-
(licensee/permittee) •
with a principal place of business/residence at:
•
7—D Huntington Ave. , S. Yarmouth, MA 02664 }
(City/State/Zip)
do hereby certify, under the pains and penalties of perjury, that: I .
(i I am an employer providing the following workers' compensation coverage for my employees working on this 1
job.
•
•
• AETNA Commercial 'Ins. Div. • 006C22790586CAA• ,
Insurance Company
Policy Number
• a
•
(j I am a sole proprietor and have no one working for me. ?
Y
(1 1 am a sole proprietor, general contractor or homeowner (circle one) and have hired the contractors listed below i
who have the following workers' compensation insurance policies: f
' Name of Contractor • , Insurance Company/Policy Number
•
•
Name of Contractor Insurance Company/Policy Number
• . : i
. s
Name of Contractor Insurance Company/Policy Number t
•
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 d
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 CompensationAct
•
1.understand that a copy of this statement will be forwarded to the Department of Industrial Accidents'Office of insurance for coverage 3
verification and that failure to secure coverage as required under Section 25A of MCL 152 can lead to the imposition of criminal penalties 't
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 Ordei and a •
line of 5100.00 a day against me. '
Signed is day of Oa>6 e Ir• . , 19 J
t�. i g
Press Thermco, Inc. • i
Licensee/Per Klee / t
Licensor/Permiaor • i
1