HomeMy WebLinkAboutBLD-93-849 -* - Tk4o TOWN OF YARMOUTH
'QF.f,t. k-y •
c. " - Application for a Permit to Build No. 84
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UPOW FINAL APPROVAL Pt/ II"/— 3 MAP LOT Z ?I-3
FEE NUST ACCOMPANY THIS APPLICATION. DATE /l// 7 19 9-3
The u)dersigned hereby applies for a permit to build 1 //1/4/93
accor ng to the following specifications
arae of property owner 2 / . i47 Aet<c6a— Tel.
Address/i 7�osaent4f
2.Nane of Architect(if any)
,�u., ' Tel.
fa
a Naris of builder v Address
4. Li4ise No. Tel.
5. Nane of Mason Address
6.�License No. Tel.
(."Construction address i/3 o4oh/ pa.7 fes, Sb .-2/ Ar-o �L/��
I Flood / District
a Datrlof subdivision Approval / plain zone Zone
9. Private dwellin ] Estimated Cost �O NOT WRITE IN THIS SPACE
( J Type f room No.
10. Multifamily ❑ /apv: 0a t° ¢ �" `"� cf� 1
11. Commercial 0 71e�2t�-a-ion-�_� I V a Kitchen
12. Other o , / Dining Rm.
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13. No. cf stories �� J1 Living Am. —
U-0 Bed Rm.
14. Foundation — Full 0 Half.I Crawl 0 Slab 0
Bath
15. Materials — Wood 0 Cement 0 Other 66 Deck
• Closed porch
16.Type of heat — Oil 0 Gas K1 Electric 0 Other ❑ p -ii ,,TJ2� Family Am. _
17. Garage — 1 0 2 ❑ @Apa' N/tr'D 1 ' Sun room
18. Swimming pool - Size Garage
li
19. Storage shed — Size Shed
' 2a Stove— Wood 0 Coal 0 Alterations
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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. DistaIice from nearest building: Front e Ft. side Ft. side ' Rear
24. Distance back from line or street From rear lot line Side line
' 25. H.I.C. .No. ,
LOT RELEASED BY Signature /'4442 ! lAdt a bO t
PLANNING BOARD Address'
Date; I '
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Suggested Affidavit for Home Improvement Contractor Permit Application .
For Omce Use Only F C/NAME OTY/I OWN
Permit No. . re 7�/ 4'�
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-casting owner-occupied building 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: 4/04.1 407 • Est. Cost L767, 00
Work q3 niJl 4 'o mad .
Address of � / �—CrYtO -.�,� ,
Owner Name( A r)y14),Z iy 140-7 1-/t 1
Date of Permit Application: aei a? /993
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
4Owner 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:
Date Contractor Name Registration No.
OR: •
Notwithstanding the above notice, I hcreb, apply for a permit as the owner of the above property:
a A _
Dat Owner Name
/ TOWN OF YARMOUTH
BUILDING DEPARTMENT
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
DATE i 79 /1f3 •
JOB LOCATION /93 /-e/Y6 frat7th) 24/ve &' �i/q///JSe///l /#tet
NUMBER STREET ADDRESS SECT N OF TOWN
"HOMEOWNER" 2)//o< /fji2-S.ayg&a /rnuredC061 ..? 9,-.34-51
NAME HOME PHONE WORK PHONE
PRESENT MAILING ADDRESS 7/ i d ete..dBrerY21( e/) C
\ WOic-14 7)94, 0 /96 .6
CITY OR TOWN STATE ZIP CODE
THE CURRENT EXEMPTION FOR "HOMEOWNER" WAS EXTENDED TO INCLUDE OWNER-
OCCUPIED DWELLINGS OF ONE OR TWO UNITS AND TO ALLOW SUCH HOMEOWNERS TO
ENGAGE AN INDIVIDUAL FOR HIRE WHO DOES NOT POSSESS A LICENSE, PROVIDED
THAT SUCH HOMEOWNER SHALL ACT AS SUPERVISOR. (STATE BUILDING CODE SEC-
109.1.1)
DEFINITION OF HOMEOWNER:
PERSON( S) WHO OWNS A PARCEL OF LAND ON WHICH HE/SHE RESIDES OR INTENDS TO
RESIDE, ON WHICH THERE IS, OR IS INTENDED TO BE, A ONE OR TWO FAMILY
ATTACHE D OR DETACHED STRUCTURES ASSESSORY TO SUCH USE AND/OR FARM
STRUCTURES: A- PERSON WHO CONSTRUCTS MORE THAN ONE HOME IN A TWO-YEAR
PERIOD SHALL NOT BE CONSIDERED A HOMEOWNER, SUCH "HOMEOWNER" SHALL SUBMIT
TO THE BUILDING OFFICIAL, ON A FORM ACCEPTABLE TO THE BUILDING OFFICIAL,
THAT HE/SHE SHALL BE RESPONSIBLE FOR ALL SUCH WORK PERFORMED UNDER THE
BUILDING PERMIT. (SECTION 109.1. 1)
THE UNDERSIGNED "HOMEOWNER" ASSUMES RESPONSIBILITY FOR COMPLIANCE WITH THE
STATE BUILDING CODE AND OTHER APPLICABLE CODES, BY-LAWS, RULES AND REGU-
LATIONS.
THE UNDERSIGNED "HOMEOWNER" CERTIFIES THAT HE/SHE UNDERSTANDS THE TOWN OF
YARMOUTH BUILDING DEPARTMENT MINIMUM INSPECTION PROCEDURES AND REQUIRE-
MENTS AND THAT HE/SHE WILL COMPLY WITH SAID PROCEDURES AND REQUIREMENTS.
HOMEOWNER'S SIGNATURE ->tis ,��p Jyy,r jCfi��9�2.�OL
APPROVAL OF BUILDING OFFICIAL
INSURANCE COVERAGE:
I have a current Iiabuity Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes ❑ No
If you have checked des, please indicate the type coverage by checking the appropriate box. •
A liability Insurance policy 0 Other type of Indemnity 0 Bond 0
OWNER'S INSURANCE•WAIVER:l am aware that the licensee does not have the insurance coverage required by
Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Owner ❑ -, Agent ❑
Signature of Owner or Omer s/cent ; J
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7 COMMONWEALTH OF MASSACHUSETTS
E.
DEFAR:MEri?OF INDUSTRIAL ACCIDENTS
600 WASHINGTON STREET
• James Camvoe� BOSTON, MASSACHUSEI IS 02111 •
Gom n ssroner WORKERS' COMPENSATION INSURANCE AFFIDAVIT •
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1,
(licensee/pa-mince)
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• with a principal place of business/residence an • •
(Ciry/Sate/Zip)
do hereby certify, under the pains and penalties of perjury,that:
(] 1 am an employer providing the following workers' compensation coverage for my employees working on this
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job.
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Insurance Company Policy Number
�(1 I am a sole proprietor and have no one working for me.
/[ ] I am a sole proprietor, general contractor o • • (circle one)and have hired the contractors listed below
who have the following workers' compensation insurance policies: -•••..•• • .• -
�9int 4
Name of C ntraaor Insurance Company/Policy Number . .
Name of Contractor Insurance Company/Policy Number .
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Name of Contractor Insurance Company/Policy Number -• •`
®•••••-I am a homeowner performing all the work myself.
NOTE.Pleue 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 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 renuired under Section 25A'of MGI.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. A t
Signed this �Y��'.t-sr)2n/dn day of (CU o29 , 19 93
Licer:see/Perm:net' • Licensor/Permittor