HomeMy WebLinkAboutBLD-93-848 /I
i'd 7.-; :SO 'tit ?-ITOWN OF YARMOUTH CK Feta' ao/4'r/93
AT ACNFCS � :� ��Q�
V,,< ..,Fe•*g; Application‘for, a,Permit to Build No..�L W
JPON FINALAPPROVAL pS/1 1 3 MAP i)'cr LOT Cr P-/
FEE MUST ACCOMPANY THIS APPLICATION. DATE 1`9 3_3
The undersigned hereby applies for a permit to build /////93
according to the following specifications 11/1/
I- zo3-966'
1. Name of property owner f1 r A Hit OW c DI 016Qucluh ham el. on 2-
Address fel Ota ILIvey 14191mia.1 (JJTll-ah/ Conn CJG954ri7
2.Name of Architect(if any) Tel.
311 Name of builder hal
.crvo (CG. Address if County Drive- iDeslrl► 5
4!License No. 00743-/ Tel. 3S5 --5(z-
5. Name of Mason Address
6. License No. Tel.
7. Construction address I(0 1Ol,n 1-1-alt Cur I yalrntouk brl-
Flood District
8. Date of subdivision Approval plain zone 6 Zone It-
9. Private dwelling S . ,4 .. Estimated Cost' DO NOT WRITE IN THIS SPACE
Type of room No.
10. Multi family 0 I 7 5CM 00 eLcSILTS 2-
11.
11. Commercial 0 Ic 1 s r Kitchen
12. Other 0 /dQ DiningRm.
, � Living Rm.
13. No. of stories
` )141. 2-5-- Bed Rm.
14. Foundation — Full ®, Half 0 Crawl 0 Slab 0 Bath /
15. Materials — Wood a Cement 0 Other 0 Deck
16.Type of heat — Oil 0 Gas IX. Electric El Other 0 Closed porch
Family Rm. /'
17. Garage — 1 0 2 ❑ Sun room
18. Swimming pool - Size _ . „, ; Garage
19. Storage shed e— Size Shed
20. Sto�e — Wood 0 Coal 0 Alterations
21. Siz IIof 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
2a Distance from nearest building: Front Ft. side Ft. side Rear
' 24. Dista�ce back from line or street Fro ear lot line / Side line
25. H.LC.p,1No. 10 I Lig 9 LOT RELEASED BY Signature // g ,4i4
, r' kt
• PLANNINGBOARD Address 67,0f/me Priv°
Date I Devi„r5 m4SS a263n /
, �6�2a193
BUILDING PERMIT APPLICATION SIGN OFF 0.2/iA
K SIN ! t 4•r O3UILDING PERMIT II:
APPLICANT: 1`
YOa
ADDRESS: 14 C,,00,eA,00!brrJie. DvitKK TELE. NO. : 34 S'S/ZS' DATE FILED: Oaf- HIV/93
BLDG. SITE LOCATION: t4L •'(H [fall C-ar MAP/l: LOU:
THE FOLLOWING INFORMATION OUTLINES THE PR EDURAL STEPS REQUIRED TO OBTAIN A PERMIT TO BUILD,
ALTER, OR ADIS TO A, STRUCTURE WITHIN THE TOWN OF YARMOUTH. THE BUILDING DEPARTMENT WILL DETER-
MINE COMPLIANCE TO THE' FOLtOWINNA) ZOIIING REQUIREMENTS (B) HISTORICAL DISTRICTS (C) FLOOD
PLAINS ZONING. '•THE.BUILDING DEPARTMET1WILL BE RESPONSIBLE FOR ASSISTING THE APPLICANT THOUGH
THE FOLLOWING DEPARTMENTS:
RESIDENTIAL AND/OR COMMERCIAL BUILDING
IS/ i
r UMI ,
WATER DEPARTMENT:, .0 1 I DETE_HT_ES)'eC _IANC'LOA(k T I� AVAYLABILITY. -
ENGINEERING DEPARTMENT:' 'DETERNINESI eO VLYAI�CE'FOR' PARKING AND DRAINAGE.
CONSERVATION COMMISSION: DETERMINES COMPLIANCE TO WETLANDS ACTS, I.E. : IF LOT(S) BORDER ANY
1t TYPE OF WETLANDS, STREAMS, PONDS, RIVERS, OCEANS, BOGS, BAYS, MARSH
!- tLAS, ETC? iTL p.{
HEALTH DEPARTMENT: 0.72 s DETERMINES COMPLIANCE/ TO'STATE-AND TOWN REGULATIONS, I.E. : REQUIRE-
' 'MELTS FOR SEPTAGE DISPOSAL-Alia -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. -
., --" t ii „ r 1 . 7
TUE FOLLOWING DEPARTMENTS MUST SIGN OFF, IN TILE RESPECTIVE ORDER, PRIOR TO BUILDING INSPECTOR
ISSUING THE REQUIRED BUILDING PERMIT:
REVIEWED BY: ti. r` r,-- ,
1. WATER DEPARTMENT' /.'//),,, ,4 ! (74,1;,>-,, DATE: i'^ -1443 N/A: •
2. ENGINEERING DEPARTMENT: t -, , . %.', r1+1 DATE: N/A:
3. CONSERVATION: . DATE: N/A:
4. HEALTH DEPARTMENT ! . DATE: /0 - 11-9' 3 N/A: '
V MUST• AL AND/OR COMMERCIAL PERMITS
5. WIRING INSPECTOR:. DATE: N/A: 4
6. PLUMBING INSPECTOR: DATE: N/A:
7. FIRE DEPARTMENT: K DATE: N/A: ,•
SC 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.
COMMENTS:ks )t'-i.--%' -- i"^ 'C. 4-nY- ---, 77-74-:" ✓ I-c':% .l /^'/2T' 741/ )S -.
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BLM/89 7� /0%/93
•
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• r • COMMONWEALTH OF MASSACHUSETTS
• " DEPAICMENT OF INDUSTRIAL ACCIDENTS ' "
•
3. • '600 WASHINGTON STREET
BOSTON,'MASSACHUSEITS'02111 •
James J Campoei, +.. , t t . - $ •
Comm:sstone WORKERS' COMPENSATION INSURANCE AFFIDAVIT •
•
Pav{ccu` ( ' Slid —
(licensee/permiflee)
• with a principal place of business/residence at: nuts Li Courier Do up, • DottutIr s ' ►`ASS 0263 t?
(Ciry/Sute/Zip)
do hereby certify, under the pains/and(penahieso{perjury,that; ,-t. ; ••
[) I am an employer providing the foIldwing wank& compen atidn coverage for my employees working on this
job. - I rr7
•
Insurance Company ' I ' tone-Number
•
I 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
Q I am a homeowner performing all the work myself.
NOTE.Please be aware that while bomeowners' who employ persons to do maintenance,construction or repair work on a
dwelling of not more thah'three units'io which the homeowner'illo resides or on the grounds appuriegant thereto are not generally
considered to be employers under the Workers' Compensation Act(CL C. 152,sect. 1(5)).application by a homeowner fora 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 secure coverage as required under Section 25A'of MGL 152 can lead to the imposition 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$100.00 a day against me.
Signed t• • / ,i / day of (1444 be , 19 9 3
, ' Lt.
Lic^ .sceiPermiret LicensoriPcrms..or
Suggested Affidavit for Home Improvement Contractor Permit Application
For omce'llse only .. 1 f NAME OF CITY/TOWN
Permit No. ' , 't�.' ! ti4 ' ainftoV /nee
Date ) i I Y
) ettiVieJii"
( ' ,jL t a ! / IAFF AvAVIT t a•
• ! f ��"� 4I
i , ( ) t Home Improvement Contractor Law
• Supplement to. ermit Application
li.wYc
MGL d.142A requires that the"reconstruction,alteration.renova(f,'on.repairLmodemization.conversion.inprovement,removal.demolition.
or constriction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units....or
I to structures which are adjacent to such residence or building"be done by registered contractors,with certain exceptions,along with other
t requirements. "//{{ . rr r
Type of Work: 4N14N �'Q"Stfl4M F ce .' doce4' kMloonEst. Cost IIf $50.00
Address of Work `(p S AY% ikit k,9
Owner Name: QIeke Oaf'
h� kcc.v .
►�
Date of Permit Application: l IL+ r ei / I qg
I hereby certify that:
Registration is not required for the following reason(s):
Work excluded by law
_Job under S1,000
Building not owner-occupied
Owner pulling own permit
Other (specify)
Notice is hereby given that:
OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED
CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE
' ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL
c. 142A.
Signed under penalties of perjury:
I hereby apply for a permit as the agent of the owner:
t%!- itt ►qq3 Pc (y Sot ,4- fin tie
Date f Co tractor Name Registration No.
OR:
. Notwithstanding the above notice, I hereby apply for a permit as the owner of the above property:
Date Owner Name
•
i - J
1
TOWN OF YARMOUTH
• BUILDING DEPARTMENT
• CONSTRUCTION SUPERVISOR FORM
PLEASE PRINT: . '
JOB LOCATION: j & • JOK (fall gad/4 %4• Y- .. t' • VONA('�f.offr
NUMBER ,/J ' . STREET VILLAGE
OWNER OF PROPERTY: - ' DIG ' ft/C,,161
CONSTRUCTION SUPERVISOR: ' • ' ' Ob 1'f3 1 34 s-cIz s
• NAME .._c{141.14 .
. LICENSE NO. PHONE NO. • ,
• ADDRESS: 4 eov tt • Qrsvt • l'ils VG.s 0 2(13 b -
- • LICENSED DESIGNEE:
(IF OTHER,THAN SUPERVISOR) NAME LICENSE NO. .
• 2.15 RESPONSIBILITY OF•EAC}4LICENSE..HOLDER: • •.$, y..,,lni , �'' ,
- ,
• 2.15.1 THE LICENSE HOLDER SHALLABELFULLY, AIND(CO}L TELYA,RESPONSIBLE FOR ALL WORK FOR WHICH HE
' IS SUPERVISING. HE SHALT. BE RESPONSIBLE FOR SEEING THAT ALL WORK IS DONE PURSUANT TO THE STATE
BUILDING CODE AND THE DRAWINGS AS!APPROVEA ,BYITeE BUILDING OFFICIAL
, .. , _.A.rr �� •
•
2.15.2 THE LICENSE HOLDER SHALL BE),RESPONSIBWrE TO ,SUPERVISE THE CONSTRUCTION, RECONSTRUCTION;
' ALTERATION, REPAIR, REMOVAL OR DEMOLITION INVOLV Nb TfE 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 .
TE
CODE AND THESE RULES AND REGULATIONS. IN THE EVENT AT 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 DEPARTMENT. ' " ' • - '
I HAVE READ AND UNDERSTAND MY RESPONSIBILITIES UNDER THE RULES AND REGULATIONS ,FOR LICENSING CC'N-
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. -';t ,.: r� ✓:i, ' '• I r; f ,i i `f .- ..-,- . -
INSUAANCE COVERAGE: t. ` - - : • -r_
I have a current liability insurance policy or its substantial equivalent which meets the requirernents cf MCL1Ch.152 :h'_ " ' .
Yes - b. r:No ❑ ...., , . . . .. _
If you have checked=. please indicate the type c average by checking the appropriate boz - :x
A liability insurance pc:icy ® Other type of :.idemmty 0 .- Bond 0 - — : — '
1 . : ..
i CWNER'S INSURANCE WAIVER:1 am aware that the rcensee deei rot have the insurance ceverge required-qv -
C,..apter 152-f the Mass: General Laws. ane that my signature cn th:s permit :c ication war:es this requirement.
Check one:
Owner: Agent 0
S:gnacure m Owner or Owners Age •
SIGNATURE: At , , its AA BUILDING OFFICIAL APPROVAL:
I - . ' ' - -- ----- - - ------- - --
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