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HomeMy WebLinkAboutBLD-93-847 o TOWN OF YARMOUTH ° reA) VMsill o 44 HI - k MAT M['f' ATI 4°.c*• ,cg Application feria Permit to Build No. 217 gi UPON FINAL APPROVAL �I-i-C3 MAP �'� LOT Y`3 FEE MUST ACCOMPANY THIS APPLICATION. DATE. 1=-1,---19-9„ 3 The undersigned hereby applies for a permit to build x`/4//p- 3 according to the following specifications //Piga 1. Name of property owner A), //Ow 5f. Po, %✓'ks r Tel. 775-53t Address 7 76 /Lt a,:t SF �„o /1/4/1/41- ,„; nt 4- 2.Name of Architect(if any) � " �/ Tel. 3. Name of builder Robert/11 , 7-0/9-11- Address 33 'Skirtf tate Ojferv;/¢(4+ 4. License No. SOC 5/ Tel. 77k- 350 5 076 sr 5. Name of Mason Address 6. License No. Tel. ' 7. Construction address 33 /fin re// A //e t /.f 44,i4 G /.J)/ Flood /District R_ y 0 8. Date of subdivision Approval plain zone C- Zone 9. Private dwelling 0 Estimated Cost `CQP DO NOT WRITE IN THIS SPACE J/ ,.' Type of room No. 10. Multi family 0 / /r, (VD t' �-19-`13 /D" /"�7 „/q3 2 cro-r,,s 7 11. Commercial f� Jl/G0[ Kitchen 12. Other 0 c Dining Rm. 7 PMC 0-3S, — Living Rm. 13. No. of stories 0n a __ tt Bed Rm. 14. Foundation — Full 0 Half 0 Crawl 0 Slab BY '2_ "c °v • roraI'cP. Bath W 15. Materials — Wood Iment 0 Other 0 ro�'3y-L Deck �3 S"'c 16. Type of heat — Oil 0 Gas Ly'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 I 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 ide line 25. H.I.C.R. No. ���/�� LOT RELEASED BY Signature PLANNING BOARD Address 17 S"*J2J Z-a4,4. Date Orriety,/4/ 44-- OZ6SS �/V / I, 9 1 BU/ILDING PERMIT APPLICATION SIGN OFF APPLICANT: (o6crF /`7//e6/tit N'' BUILDING PERMIT IP: ADDRESS: )7 Su-nfi/' Com. eoSh,-v/Yo , TELE. NO. : 77P- s'9i9. DATE FILED: BLDG. SITW LOCATION: 33 /Ink,/ // V/e/, / MAPli: LOT/l: THE FOLLOWING INFORMATION OUTLINES THE PROCEDURAL STEPS REQUIRED TO OBTAIN A PERMIT TO BUILD, ALTER, OR ADD TO A STRUCTURE WITHIN THE TOWN OF YARMOUTH. THE BUILDING DEPARTMENT WILL DETER- MINE COMPLIANCE TO THE FOLLOWING (A) ZONING REQUIREMENTS (B) HISTORICAL DISTRICTS (C) FLOOD PLAINS ZONING. THE BUILDING DEPARTMENT WILL BE RESPONSIBLE FOR ASSISTING THE APPLICANT THOUGH THE FOLLOWING DEPARTMENTS: RESIDENTIAL AND/OR COMMERCIAL BUILDING WATER DEPARTMENT: DETERMINES COMPLIANCE OF WATER AVAILABILITY. • ENGINEERING DEPARTMENT: DETERMINES COMPLIANCE FOR PARKING AND DRAINAGE. CONSERVATION COMMISSION: DETERMINES COMPLIANCE TO WETLANDS ACTS, I.E.: IF LOT(S) BORDER ANY TYPE OF WETLANDS, STREAMS, PONDS, RIVERS, OCEANS, BOGS, BAYS, MARSH LAND, ETC. HEALTH DEPARTMENT: DETERMINES COMPLIANCE TO STATE AND TOWN REGULATIONS, I.E. : REQUIRE- MENTS FOR SEPTAGE DISPOSAL AND OTHER PUBLIC HEALTH ACTIVITIES. FIRE DEPARTMENT: DETERMINES COMPLIANCE TO STATE AND TOWN REQUIREMENTS FOR PERSONAL SAFETY, PROPERTY PROTECTION, I.E. , SMOKE DETECTORS, SPRINKLER SYSTEMS, ETC. THE FOLLOWING DEPARTMENTS MUST SIGN OFF, IN THE RESPECTIVE ORDER, PRIOR TO BUILDING INSPECTOR ISSUING THE REQUIRED BUILDING PERMIT: REVI BY: te . WATER DEPARTMENT DATE: - N/A: 2. ENGINEERING DEPARTMENT: ^ DATE: N/A: 3t,CONSERVATION: l( / / DATE: N/A: CA: HEALTH DEPARTMENT �j �` DATE: -.2_y- 93 N/A: ( INDUSTRIAL /0 COMMERCIAL PERMITS &. WIRING INSPECTOR: i eini ;% �� ✓� DATE: ,q' 93 N/A: !&(PLUMBING INSPECTOR:1 DATE: N/A: OcFIRE DEPARTMENT: DATE: N/A: PLEASE NOTE ALL STUMPS AND/OR BRUSH MUST BE DISPOSED OF AT AN APPROVED SITE. A SIGNED RECEIPT FROM THE DISPOSAL SITE MUST BE SUBMITTED TO THE BUILDING DEPARTMENT PRIOR TO ISSUANCE OF THE BUILDING PERMIT. ,wJ COMMENTS: 314) & ) (IDE /1,//��c4-v/ t&n/ /G.YT y/NT/Ls -r/off' ///! At off)L'/-//'1 Pert gLrLSON • BLM/89 /DA-, • b COMMONWEALTH OF MASSACHUSETTS `419' DEPARTMENT OFINDUSTRIAL ACCIDENTS - - ' 600 WASHINGTON STREET - _ .. _. James J Canteen BOSTON, MASSACHUSETTS 02111 • comm sstone' ORICERS' C MPENSATION INSURANCE AFFIDAVIT • . 4(7kt (licensee/permittee) - - • with a principal place of business/residence at•. l -_. 3 ? s ilti/� ®s1ia,l‘ © 26'IT— (cry/State/Zip) do hereby certify, under the pains and penalties of perjury, that: - - :-j--- • --- - • - ... • • [] I am an employer providing the following.workers' compensation coverage for my employees working on this job. • • Insurance Company Policy Number am a sole proprietor and have no one working for me. ( ) I am a sole proprietor;general contractor or homeowner (circle brie)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 - 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. 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 MCL 152 can lead to the imposition of criminal penalties consisd'ng of a fine of up to SI500.00 and/or imprisonment of up to one year and civil penalties in the form of a Stop Work Order and a fine of$100.00 a day against me. lk Signed this (e day of , 19 ( 3 VliAkii L censceiPermtace- LiceasoriPermiaor TOWN OF YARMOUTH • BUILDING DEPARTMENT . ' CONSTRUCTION SUPERVISOR FORM PLEASE PRINT: / JOB LOCATIOIr: 3.3 . ./11seL //n ter , L Ye 14 L- • NUMBER STREET VILLAGE OWNER OF PROPERTY: ' Ale"7O�W SIreel` /Cea/ / r`+•s1 • CONSTRUCTION SUPERVISOR: _ •I�o'oet /1/l,7'�4et( - • . .•SooS/- 72V' 5519 . . .. _ NAME . . LICENSE NO. , PHONE NO. . . ADDRESS: • 33 • Suuszf. : .. , •©Stun,'/o mg oz- Ss' .. .:: . :' 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 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 3E 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 CCI- 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 COVER GE: I have a current i tty insurance policy or its substantial equivalent which meets the requirements of MGL1th.152 Yes ' . No CIranete/CI .1:NS.Co ' .36 yak 60q/ - 610 If you have checkedis. pleasele � indicate/ the type cwerage by checking the aporcpriate box. A liability insurance pciicy LH' O:her type of :indemnity 0 Bond 0 • • . OWNER'S INSURANCE WAIVER: I am aware that the ucensee does rot have the insurance coverage required by Chapter 152 of the Mais: General Laws, ano that my signature on the permit ::plication waives this requirement • Check one: • - Owneru Agent CI • Signature or Circler or Owners Agent ' SIGNATURE: BUILDING OFFICIAL APPROVAL: • ' , ?lky/S 4, , ^. i I --i . iete' I 1N3(' �0 71/41 I r 1')rn ry 32''( '/f� ,� o, .? fi ,773.10 --.• -7�dvv, ji �`p 1 30 441 'vcfr) 17/61 `� Z A47,- • v ' b f & fhy '--12-717111.1 }'n i?�?l Xy .tel/ nid. 0 �b�H .tiLI .1.7(1 J 56 0 ?nell g "AO-Wrg` �D6��1 - i - 9 8 „ �/d''ern ,, s. $mQO/YJM• 9r--- Cli Y ..� ...i.• �✓�/t It 111 ..... 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