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Home My WebLink AboutBLD-93-844 . 0c• dik e u', /% ;j' 3 $ Y : ,`� TOWN OF YARMOUTH aire41 10/10? H�,"4%1 Wg / Application for a Permit to Build No. FIN UPON FINAL APPROVAL t/U f V Jag'' MAP / 7 LOT U Y/ FEE MUST ACCOMPANY THIS APPLICATION. DATE io,u 19 The undersigned hereby applies for a permit to build /b/A q 9a according to the following specifications . 1. Name of property owner Mw- MP-S Mu 12-Wr /C/174:3483S- Address /ait ?7/-4835Address Sr At-4°J p0AAD w. yAniatM 2.Name of Architect(if any) Tel. 3. Name of builder Jernsy Cntalts,cia Address Go 60-0.100-4/J Lua wnt 4. License No. OP-%(o Tel. 77!-oio3 5. Name of Mason Address 6. License No. Tel. 7.Construction address TS" At•bq1 8440 t'• YA141A11.1 Flood C District n 8. Date of subdivision Approval plain zone (-) Zone it C 9. Private dwelling 0 Estimated Cost DO NOT WRITE IN THIS SPACE (/ /aT/z Type of room No. 10. Multi family 0 F I U ifo S, y Sip/T2 l 11. Commercial 0 o K Ur" Kitchen 12. Other Sof Ait� Dining Rm. er.S i� Living Rm. 13. No. of stories 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 0 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 r-ar lot line Side line 25. H.I.C.R. No. / LOT RELEASED BY Signature ` ' A 1101,PLANNING BOARD Add -- - -"—s"- - • ir dAMfl) -. niu. Date /liiirrv.vii / 41,4 .024.0/ • TOWN OF YARMOUTH ` • BUILDING DEPARTMENT • CONSTRUCTION SUPERVISOR FORM ' ' PLEASE PRINT: ' • ' ' • • JOB LOCATION: 57.57 A- t Uc7`1 pabt, War 1j%2 sf.rrI . NUMBER • . . STREET VILLAGE •. • .OWNER OF PROPERTY: ' M✓le242 ekt • • • CONSTRUCTION SUPERVISOR: J�Fgc`r 1.-oS'tsl+J • 04 -t•1D(o 77/-0303 • • • NAME • LICENSE NO. PHONE NO. . . . ADDRESS: 60 • icr J tN 4p Jga.i WM( 4-6/140Ms CT2 ° i LICENSED DESIGNEE:.' - • • . . (IF OTHER.THAN SUPERVISOR) NAME LICENSE NO. • - • 2.15 RESPONSIBILITY OF EACH LICENSE HOLDER: ' 6 - ' •• 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 • COMMONWEALTH, 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 IMMEDIATELY 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 LICENSING CC.I- 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. . ' INSURANCE COVERAGE: . . _ . . . -. . ... :•_ .. I have a ourrst2 liability, insurance pclicyor is substantial equivalent which meets the require-encs of MGL10h.152 '..:"• -• 'r If you have check-et-11s please indicate the type cavern.? by checking the apprcpbar:riate b _ - _-"^ -'•' :1-;s- A liability insurance pc:icy 0 Other type of indemnity❑ ••• Bond ❑ . O'NNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage.requirec` - _;i Chapter 152 of the Mais: General Laws. ana that my signature cn this permit :cp:ic:ticn wanes this iequiren:ent. • i. . Check one: • • _Owner° Ag_:0 • ' :.gaacurece at Owner aer s agent • • SIGNATURF1 ' / fir _. _BUILDING OFFICIAL APPROVAL: ~ ------------ • • Suggested Affidavit for Home Improvement Contractor Permit Application- -s - - For Office Use Only NAME OF CITY/TOWN Permit No. Date • AFFIDAVIT Home Improvement Contractor Law • ' Supplement to Permit Application MGL e.142A requires that the"reconstruction,alteration.renovation,repair,modernization.conversion,inprovement,removal.demolition, or construction of an addition to any pre-existing owner-occupied budding 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: I N Sth S�Yue tfrt Est. Cost iota Address of Work Sf At-40Q Ron Wcy YAltttlouflj Owner Name: MP—. MuPatfo'( Date of Permit Application: /017-t-7/, I hereby certify that: Registration is not required for the following reason(s): _Work excluded by law Job under 31,000 _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: J j 644ST'Ezr) /007 3Y D�o e 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 • .ti- • • • • `=_=+• _IP COMMONWEALTH OF MASSACHUSETTS DEI`ARIMENT OF INDUSTRIAL ACCIDENTS 600 WASHINGTON STREET • Dames Camooei; BOSTON, MASSACHUSETTS 02111 Comm:sstoner • WORKERS' COMPENSATION INSURANCE AFFIDAVIT • • (licensee/permittee) • with a principal place of business/residence an. • • Coo 3=0\141441/3 }-Q¢yvlcua 14 ti Avins MR- 014 t • (City/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. • °P Da itfGM✓M.n'Lo../ap n e OS 1/1% q3 E . Insurance Company' ' < t ' '‘ • • , Policy Number () I am a sole proprietor and have no one working for me. ( J 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: ---••• • •• --. ,s- . • . . . fir • Name of Contractor - Insurance Company/Policy Number.. . Name of Contractor - Insurance Company/Policy Number - - Name of Contractor Insurance Company/Policy Number .. _ t. 0 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(CL 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 iccure coverage as required under Section 25A'of MGL 152 can lead to the impoiition of criminal penalties consisting of a fine of up to$1500.00 and/or imprisonment of up to one year and civil penalties in the form of a Stop Work Order and a fine of S100.00 a day against mc. Signed this y Co day of 0cT , 19 -$ tip/0.1 mit•.ec' LicensoriPermirror