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:
70M OF BUILDING � r _ CI� 107�
.PERMIT
Sept. u, 2DOO s-02 -�40
DATE PERMIT NO.
APPLICANT M. .ADDRESS 28 S- Y-
INO.) (STREET)
PERMITTO ADDT'1 (—) STORY
(TYPE OF IMPROVEMENT) NO.
(PROPOSED USE)
NUMBER OF
DWELLING UNITS
(CONTR'5 LICEN5E)
ZONING
AT (LOCATION) 89 Acres Ave, N• Y• DISTRICT It-25
(NO.) (STREET)
BETWEEN - AND
ICROSS STREET) ICROSS STREET)
LOT
SUBDIVISION 2412 LOT 747 BLOCKHp3 1_SZE
i
BUILDING IS TO BE FT. WIDE BY FT. LONG BY FT. IN HEIGHT AND SHALL CONFORM IN CONSTRUCTION
TO TYPE 5-B USE GROUP RA BASEMENT WALLS OR FOUNDATION
(TYPE)
AREA OR
VOLUME ESTIMATEDCOST-$ 14.900.00 FEEMIT
•
ooln
(CUBIC/SYyQ;�DARE FEET(
OWNER A. �L.Eick BUILDING DEP
I, ADDRESS-89 A=es Ave. W. Y. BY
I
INSPECTION RECORD
DATE
NOTE PROGRESS CORRECTIONS AND REMARKS
INSPECTOR
9�q�L
C
f_ " ' ,
4L ;a
ONE & TWO FAMILY ONLY - BUILDING PERMIT
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
Town of Yarmouth Building Department
1146 Route 28 - Yarmouth, XIA 02664-4492
Tel: (508) 398-2231 x261 - Fax: (508) 398-2365
trice Use Only Planning Board Information Assessors Department Information:
Permit No. '�� a� Date Plan Type M cdP for
Endorsement Date d 2 2—
Permit Fee $l✓4z, — _ ._ Ord New
Recording Date
Deposit Rec'd. $ d5.—Date % 1.4 Property Dimensions:
Plan No. _
Net Due $/a 5 Other Lot Area (sf) Frontage (lt) Lot Coverage
Section 2 - Property Ownership/Authorized Agent
2.1 Owner of Record:
Mailing Address
+
2.2 Authorized Agent:
A�zEy H NG��2 a�wy�r�s/�Ary� YAK N�
Name (print) Mailin Ad !;/
Signa ure Telephone
Section 3 - Construction Services UN`1' 5 '2000 J
3.1 Licensed Construction Supervisor. Q/ NotAppli able ❑
a 0 A/4,?7t---{' M771 S. yAl2Kor�f; ifA 02GGf/ Ucense Number
Address C. S Q�j7 <-�' 9
�c39%- �70y- �70y QL Expiration Date
Sight a Telephone 12/3 012001
3.2 Registered Home Improvement Contractor.
Company Name Not Applicable ❑
BEST fiT wiyDow 9c- D002 CO , =fJ C-
Address License Number
IA'7 6 o
9-8 WH IT55 �AT�9 3 !�-�/�%(%� Expiration Date
Signature e Telephone Z
9-15-99 tof2 OVER
Section 4 - Workers' Compensation Insurance Affidavit (M.G.L c. 152 S 25C (6)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Faild?e.- -
to provide this affidavit will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes ... No ..........
Section 5 - Description of Proposed Work (check all applicable)
New Construction ❑ No. of Bedrooms NIA No. of Bathrooms N A
Existing Bldg. ❑ Repair(s) ❑ Alterations ❑ Addition 0- T!//2EC SFa9smi Etie%a` 96
Accessory Bldg. ❑ Type
Demolition
Other Specify:
Brief Description of Proposed Work:
,S'" So CLOXCAR c )C t nj G A €Ct c...
OF vs S S ZQ5 C E ' X 12'
Section 6 - Estimated Construction Costs
Item Estimated Cost (Dollars) to be
completed by permit applicant
1. Building / y Qj . 00
2. Electrical
3. Plumbing / Gas
4. Mechanical (HVAC)
5. Fire Protection
6.Total=(1 +2+3+4+5)
7. Total Square Ft. (new houses&adchons) /yy
Section 7a -Owner Authorization -To Pe Completed When]
Own s Ag t or Contracto plies for ildiWg rmit -
I,
hereby authorize !SEXE
my bahalf "N all matters
ignature of Owner
Section 7b - Owner/Authorized Acihht Declaration
Check Below
❑ Conservation -Commission Filing
(if applicable)
❑ Old Kings Highway & Historical
Commission approval
(if applicable)
as owner of the subject property
by this building permit application.
Date
act on
I, 14645b R, 2e!_Apixr - , as Owner/Authorized Agent
hereby declare that the statements and information on the foregoing application are true and accurate,
to the best of my knowledge and belief.
Signed under the pains and penalties of perjury.
A�r>lzF� .K . r'3c c.9N 7OZ -
Print name —
Signatu of Owner/Agent Date
9-15-99 2 of 2
TOWN OF YARMOUTH
Y''11c
..•,;; BUILDING DEPARTMENT
BUILDING PERMIT APPLICATION SIGN OFF
:applicant: &P-RRRA 1Gtt2V_P TV2-1C V— Building Permit No.:
:address: 9 AC2cS AMS W.YAR OV-19 Tel. No.: iiS-72a:5 Date Filed:
Bld,T. Site Locati
Map No.: 07 Lot No.: A
_�-/ 5✓
The follouing 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 urill determine compliance to the
following: (A) Zoning Requirements (B ,Historical Districts (C) Flood Zones. The Building Department
will be responsible for-assisting-theapplicantthrough the following departments:
RESIDENTIAL AND/OR COMMERCIAL BUILDING
WATER DEPARTMENT: " Determines Compliance of Water Availability. (applicant to obtain)
ENGINEERING DEPART:IIENT: Determines Compliance for Parking and Drainage.
CONSERVATION COXMISSION: Determines Compliance to Wetlands Acts; i.e., If Lot(s) Border any Type
of Wetlands, Streams, Ponds, Rivers, Oceans, Bogs, Bays, Marshland, Etc.
HEALTH DEPARTMENT: Determines Compliance to State and Town Regulations; i.e., Requirements
for Septage Disposal and other Public Health Activities.
FIRE DEPARTIIIENT: 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:
RE% VED BY:
. WATER DEPARTMENT: DATE: �- - t1t1a N/A:
2. ENGINEERING DEPARTIIIF.NT: DATE: N/A:
3. CONSERVATION: P # DATE: N/A:
4. HEALTH DEPARTMENT: U DATE: 01 N/A. -
INDUSTRIAL AND InIz COMMERCIAL PERMITS
5. WIRING INSPECTOR: DATE: N/A:
6. PLUMBING INSPECTOR DATE: N/A:
i. FIRE DEPARTMLNT. DATE: N/A:
PLEASE NOTE
All stumps and/or brush must be disposed of at an approved site.
CO.NINIENTS: N/A L<k XIA A<
8/99 :applicant Signature Date
. --••• �j ,..wsuurwrw
Department of Industrial ;1 ccidents
4 1 � OfAceo!/msUp�iis
600 Washington Street
Boston, Mass 02111
v
Workers' Compensation Insurance AlMdavit
9, Y1Jo0,,-10v7-11 , /K4 oz"
'
O 1 am a homeowner performing all work myself.
0 1 am a sole proprietor and has a no one workine in any capacity
(� 1 am an employer pros iding workers' compensation for my employees working on this job.
comnans•name* REFS1 E/7'
//Vbof✓
94bt9DJ2 C
C .
address, 616 klfi IT&s JOAT'H
s,
insuranceco. GL/A124 2NSj/�Act-e'G20UP nelirvlf 2>E7vyg3aIX
[D'I am a sole proprieto . general contracto or homeowner (circle one) and have hired the contractors listed below s%ho has
the following ssorkers' compensation polices:
eauure to secure coverage as required under Section 25A of MGL 152 an lead to the impoddoa of criminal penalties of a Bag op to 51,500.00 and/or
one years' Imprisoomcnt as weU as civil penalties in the form of a STOP {PORK ORDER and a On nfSIMM a day against me. I eadentsad that s
Copy of this statement maybe forwarded to the Me of Investigations of the DU for coverage vetiQatioa. •
l do hereby certify seder the pains and penalties o�CdUrY that the tafOrmu foe provided above h mm and correct
A-is!-ew
Print name / -11-p 0b! //, SFZOIAIZR /, pfiOOe j a 9X g;Po y
oRcial use onh• do not write In this area to be completed byeityortown oBlCial
city or town: YARMODTI; _ permlt/lieease tt n8uilding Department
Q cheek if Immediate response Boardpoase is required 261 OSelectmen s OMee
p phoseM:_ (508) 398�2231' t>ort_ nQOtherhDepartment
contact person:
41"ned 3.941VA1
06/24/2030 14:45 5088329565 ` NORTHEAST INSIRAMCE
PACE 01/01
t :; �GOR�R'IFAT {3F LirBILtTi �I�fSUEAtNE aATsIMwuDam •.
L........... ......... ....... .. ... _.c Emo t 06 14/00
PRODUCER. THIS UZATIFICATF IS ISSUED A5 A MATTER OF INFORMATION
ONLY AND CONFER3 NO RIGHTS UPON THE CERTIFICATE
Northeast Insutauce Agancy,Inc HOLDER. THIS CERTIFICATEDOES NOT AM.ENO,EXTEND OR
367 Southbridge St. ALTER THE COVERAGE AFFORDED BYTHE PCUCIES BELOW.
Auburn RA 01501 COMPANIES AFFORDING COVERAGE
Scott Bulger (A144)
COMPANY
rmane Nv. F . he
AGuard insurance Group
INSURED
COMPANY
B . Merchants and Business Menlo
Alfred Belanger
Best Fit Window & Door Cc
COMPANY
C
28 White"a Path
S Tarnouth HA 02664
j
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COL;PAM,
D
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7::CC•: , � iii:iti4;•>.'• ::::a:;•; :.'.•....::.::.... •., :::.:.'.'. v...•::.: .
O TO CERTlYTHATTNp POLICIES D' NSLFANCE LISTED BELOW HAVE BEEN fS&UEO TO THE INSIfTF_D NAMEDA30VE FOR THE POLICY PERIOD ••
THIS.
INDICATED, NOTWITHET•ANDIND ANY REW REMENT. TERM OR CCNUTION DF ANY mNTRACT OR OTHER DCCUUENT WITH RESPECT TO WHICH THIS
CVMrICATE MAY BE ISSUED OR MAY FESTAPL THE INSURANCE A►FORDLD BY THE POLICIES Opsc;LSED HEREIN IS S:AJECT TO ALL THE TERNS,
G=U81CHlJs AND CONDMONO OF BUCH POLICIES. LW M3 3HOM MAY HAVE SEEN REDUCM BY PAID CLAIM &
LT�R
TYPE CF INSURANCE
roLCyTIUM1ER
POLICYEFFECTRL
DATE CWMWYT')
POLICY EVXATION
i DATE IM?1DO.M)
MITI!
B
CENERAL LNBILTTY
Z CONImERCALLOENew "'LITY
CLAIMS �X
0020346593
06/03/00
06/03/01
c3hvkkA GGREOATE
s 1000000
PRCMCM-COMP,00AGG
s 100D000
PERS0NAL&ADVN1URY
1
MACE OCCUR
CWwxs&00HTRACTOR•s/ROT
EACHOCCVRRENCe
5300000
FiRE OALIACEVPyw*Fn)
S -
-
1mEvOnomeOWNI)
63000
AUTOMOBLE
LNEtL1TY
ANYA=
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Cr'MB!N10 S.NOti UMT
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A:1 CA$= AUTDS
SC• EO AUTOS
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NONOW!IEO A1TO6
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BODLY W1URY
p`I, Ice�nq
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PROF:RTV CAMA3E
GWOELIABILITY
ANV AUTO
AUTOOfLY•EAACCIDEVT
f
OTHER THAN AUTO ONLY:
EACH ACCIOE!4T
f
A33REGATM_
S
DHSS UA8IUTY -
UMBRELLA FORM
-
EACN OCCURRENCE
AGORECAT:
f
OTHER THAN UMBRILIA FORM
f
WOPJWA COMP--NSA-MN AND
EMPLOYERS' LIABILITY
+1 LL
T TS
LL EACH ACCIDENT
1100000
A
PAA MCUIVIC11" INCH
OPFICEM ARL iJ(CL
OTHER
BYDTC030611
10/27/99
10/23/00
ELDISME•POLICY LIMIT
s500000
EL QISEAS:• EA E+r_OYPE i100D00
DESCRIPTION OF OPERA' 1OF81CCATION3WtA,CLESZP9QAL IT.Uq
)v iTtRiCllTB3iOCDER ::•:::>: < :: i:ri::::: t:r:'.:...... �R N'10E ::.,.•.•::::::......:::.:.•.•.,';<,:,
• .......... .. .. ............... ...... ....... 4.. ........ .... Kll, T7 .1 ......•
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....TOWNOPY
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ABOVE DOCREEO POLICIES lE CANCELLC39ETOMTHE
BullTown in YarmouthEN
anilding Dept
1146 Rt 2BS
ERECF, THE IWuN3 COMPAIIY WILL EYDLAVOR TO NAIL
VAA NOTICE T'O THE CL7'TPrATE HOLDER NAMED TD THE LEFT.
pUCH NOTICG SHALL ILroSE NOOCtJGATgN CR LL46LRY
Yarnouth IM 02664
HE COMPANY. RS AMNTS OR REPRESENTATIYFS
AUTf
ulger (A144)
•'�IC4aD:>ypl3Poi�,lapl+i: t�:f
,.�•r�M�n_ T��ncc��
1146ROL7E28 SOL-M YARMOUTH 1 USS.-,CHI:S=026644451
Telephone (5081 398-_2_231. Ext. _'6l — Fax t5081 398-.363
BUILDING DEPARTMENT
DEMOLITION DEBRIS DISPOSAL AFFIDAVIT
u.S
PLUMBING
SM S
I'urmant to I.G.L. Chapter 40. Section 54 and 780 CMR. Chapter 1. Section 111.5.
I herebv certifi• that the debris resulting from the proposed trod: 'demolition to be
c<tnducted at P9 AC2c dVC W .YAAH0VW_ NA OZQ3
Work Address
k it, br disposed of at the following location: bVMP.S7E22 ask wHiTEs 10A1-►•4 S,%IA(4-( JM
Said disposal site shall be a licensed solid waste facility as defined by I.G.L.
Chapter I l 1. Section I50A.
Signature of Applicant Iiate
Perinit No..
. of -,k . TOWN OF YARMOUTH
•- BUILDING DEPARTMENT
.?�,. 1146 Route 1-8. South Yarmouth. MA 02664 508-398-2231 ext. 261)
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
JOB LOCATION: 6,1zva.A k»V-AgrRtcte_ y9 Res AvE All M*11007
NAME STREET ADDRESS SECTION OF TOWN
-HOMEOWNER" 77Y-72-0.S
NAME HOME PHONE WORK PHONE
PRESENT MAILING ADDRESS A,C2ES' AV6 W j iA0I1aUT14, io�1A O2b-7 3
CITY OR TOWN STATE ZIP CODE
The current exemption for `Homeowner' was extended to include owner —occupied dwellings of one or two unit:
and to allow such homeowners to engage an individual for hire who does not possess a license, provided that sucl-
homeowner shall act as supervisor. (State Building Code Section 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 intendeL
to be, a one or two family attached or detached structure assessory to such use and / or farm structures. A persor
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 regulations.
The undersigned `homeowner' certifies that he ! she understands the Town of Yarmouth .Building Department
minimum inspection procedures and requ' ments and that he / she will comply with said procedures and
requirements. n _ _ % A / A
HOMEOWNERS SIGN
APPROVAL OF BUILDING OFFICIAL I/
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent, which meets the requirements of MGL CIL 142.
Yes C--� No 71
Ifyou have checked ves, please indicate the type coverage by checking the appropriate box.
A liability insurance policy✓ Other type of indemnity 0 Bond 0
oWNER'S INSURANCE WAIVER: I 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:
Signature o Owner or Owner's Agent Owner 0 Agent x_---
.1:homco%%nrnccxemp
310 CHR 10.99 DW Pile tea
Cro be provided by DIV)
Form 1
Ot7/tos YARM
e��j Ct kP�4TR t C.
Gosssos:.nealtb
of Xxxxaobuiretti
Request for a Determination of Applicability
Massachusetts Wetlands Protection Act, G.L m 131, §a
and the Town of Yarmouth Wetland Bylaw.
1. X. the undersigned, hereby request that the TOWN OF YARMOUTH
conservation commissions make a determination as to whether the area,
described below, or work to be performed on said area, also described below,
is subject to the jurisdiction of the wetlands Protection Act, G.L. c. 131,
S40.
2. The area is described as follows. (use maps or plans, if necessary; to
provide a description and the location off�the area subject to this request.)
Locations Street Address
Lot Numbers �-1-I.-
3. The work in said area is described below. (use additional paper, if
necessary, to describe the proposed work.)
1-1
Effective 11/10/89
s"
4. The owner(s) of the area, if not the person staking this re , has been
..given written notification of this request on (date)
,The name(s) and addresses) of the owner(s):
w •
S. Z have filed jvccigplete copy of this request with the appropriate regional
of c t sachusetts Department of Environmental Protection
(date)
DEP Northeast Regional office
10 commerce Way
Woburn, MA 01801
DEP central Regional office
75 Grove Street
Norcester, MA G1605
DEP Southeast Regional office
20 Riverside Drive
Route 105
Lakeville, MA 02347
DEP Western Regional office
State House West, 4th Flocr
436 Dwight street
Springfield, MA 01103
6. I understand that notification of this request will be placed in a local
newspaper at sty expense in accordance with section 10.5(3)(b) I of the
regulations by the conservation cc=ission and that Z will be billed
accordingly.
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i C�tia4�E 4N O .0 LEWIS POND ti
Massachusetts Department of Environmental Protection Town of Yarmouth wetland By -Law
Bureau of Resource Protection — Wetlands Chapter 143
WPA Form 2 - Determination of Applicability
Massachusetts Wetlands Protection Act M.G.L. c. 131, §40
' General Information
From: 3. Title and Final Revision Date of Plans and Other Documents:
YARMOUTH Sketch of land at 89 Acres
axwvem commtuim
1. Applicant _Avenue, West Yarmouth
Barbara Kirkpatrick
AMme olPasan AW1V Request
89 Acres Avenue
West Yarmouth
wom
MA. 02673
Stare
2. Property Owner.
SAME AS ABOVE
IWme of PmPaly 0wrr (l dfdedd from a;;l av
Maift kdw
CITY/Town
Le code
Statc LP code
Determination
Pursuant to the authority of M.G.L c.131, §40, the
YARMOUTH
Coaservadon commission
has considered your Request for a Determination of
Applicability, with its supporting documentation, and has
made the following Determination regarding:
89 Acres Avenue
SeeetAddress
West Yarmouth 02673
Q11TOV LC code
13 J 42
AssessorsMaNPW PATIaor!
Rev.10/98
Massacbusefts Department ofEndronmental Protectien Town of Yarmouth wetland sy-Law.
Bureau of Resource Protection — Wetlands Chapter 143
WPA Form 2 - Determination of Applicability
Massachusetts Wetlands Protection Act M.G.L. c. 131, §40
Determination (cont.)
The following Determination(s) is/are applicable to the
proposed site and/or project relative to the Wetlands
Protection Act and Regulations:
Positive Determination
Note: No work within the jurisdiction of the Wetlands
Protection Act may proceed until a final Order of Conditions
(issued following submittal of a Notice of Intent or
Abbreviated Notice of Intent) has been received from the
Issuing authority (i.e., conservation commission or the
Department of Environmental Protection).
1. The area described on the plan(s) referenced above,
which Includes all or part of the area described In the
Request, Is an area subject to protection under the Act
Therefore, any removing, filling, dredging, or altering of
that area requires the filing of a Notice of Intent
❑ 2 The delineations of the boundaries of the resource
areas listed directly below, described on the plan(s)
referenced above, which includes all or part of the area
described In the Request, are confirmed as accurate:
Therefore, the resource area boundaries confirmed in this
Determination are binding as to all decisions rendered
pursuant to the Wetlands Protection Act and its regulations
regarding such boundaries for as long as this Determina-
tion is valid. However, the boundaries of resource areas not
listed directly above are = confirmed by this Determina-
tion, regardless of whether such boundaries are contained
on the plans attached to this Determination or to the
Request for Determination.
❑ 3. The work described on plan(s) and document(s)
referenced above, which includes all or part of the work
described in the Request, is within an area subject to
protection under the Act and will remove, fill, dredge, or
alter that area. Therefore, said work requires the filing of a
Notice of Intent
C 4. The work described on plan(s) and document(s)
referenced above, which Includes all or part of the work
described in the Request, Is within the Buffer Zone and will
alter an Area subject to protection under the Act Therefore,
said work requires the filing of a Notice of Intent
M S. The area and/or work described on plan(s) and
document(s) referenced above, which includes all or part of
the work described In the Request, Is subject to review and
approval by
We Cfmtndpatdy
pursuant to the following wetlands law, bylaw, or ordinance
(name and citation of law).
❑ 6. The following area and/or work, if any, Is subject to
municipal bylaw but =subject to the Massachusetts
Wetlands Protection Act
G 7. If a Notice of Intent is filed for the work in the Riverfront
Area described on plans and documents referenced above,
which includes all or part of the work described in the
Request, the applicant must consider the following
alternatives (Refer to the Wetlands Regulations at
10.58(4)c. for more information about the scope of
alternative requirements)
❑ Alternatives limited to the lot on which the project is
located.
C Alternatives limited to the lot on which the project Is
located, the subdivided lots, and any adjacent lots formerly
or presently owned by the same owner.
C Alternatives limited to the original parcel on which the
project Is located, the subdivided parcels, any adjacent
parcels, and any other land which can reasonably be
obtained within the municipality.
C Alternatives extend to any sites which can reasonably
be obtained within the appropriate region of the state.
Massachusetts Department of Environmental Protection 'town of Yarmouth wetland By -Law,
Bureau of Resource Protection — Wetlands Chapter 143
WPA Form 2 - Determination of Applicability
Massachusetts Wetlands Protection Act M.G.L. c. 13i, §40
Determination (cont.)
Negative Determination ❑ 5. The area described in the Request is subject to protection
Note: No further action under the Wetlands Protection Act under the Act Since the work described therein meets the
Is required by the applicant However, if the Department of requirements for the following exemption, as specified in
Environmental Protection is requested to issue a Supersed- the Act and regulations, no Notice of Intent Is required:
ing Determination of Applicability, work may not proceed
on this project unless the Department fails to act on such
request within 35 days of the date the request is post- k°"n
marked for certified mail or hand delivered to the Depart-
ment. Work may then proceed at the owner's risk only
upon notice to the Department and to the conservation ❑ 6. The area and/or work described in the Request is not
commission. Requirements for requests for Superseding subject to review and approval by
Determinations are listed at the end of this document.
❑ 1. The area described in the Request is not an area subject
to protection under the Act or the Buffer Zone.
C 2. The work described In the Request is within an area
subject to protection under the Act, but will not remove, fill,
dredge, or after that area. Therefore, said work does not
require the filing of a Notice of Intent
X3. The work described in the Request Is within the Buffer
Zone, as defined in the regulations, but will not alter an
Area subject to protection under the Act. Therefore, said
work does not require the filing of a Notice of Intent
4. The work described in the Request is not within an Area
subject to protection under the Act (including the Buffer
Zone). Therefore, said work does not require the firing of a
Notice of Intent, unless and until said work afters an Area
subject to protection under the Act
A67eofLb*law
pursuant to a municipal wetlands law, ordinance, or bylaw,
(name and citation of bylaw).
CONDITION:
Sono tubes be hand dug.
AUtilOrlZatlDn This Determination must be si net' b a ma'ority of the
This Determination Is issued to the applicant and delivered
as follows:
by hand delivery on
Au¢ust 7. 2000
Date
❑ by certified mail, return receipt requested on
Dare
This Determination is valid for three years from the date of
Issuance (except Determinations for Vegetation Management
Plans which are varid for the duration of the Plan).
This Determination does not relieve the applicant from
complying with all other applicable federal, state, or local
statutes, ordinances, bylaws, or regulations.
g y 1
conservation commission. A copy must be sent to the
appropriate Department of Environmental Protection
regional office (see appendix A) and the property owner (if
Aft us t 3. 2000
Date
Page 3 of 4
9
Massachusetts Department ofEnviromnental Protection Town of Yarmouth Wetland By -Law
Bureau of Resource Protection — Wetlands Chapter 143
WPA Form 2 - Determination of Applicability
Massachusetts Wetlands Protection Act M.G.L. c. 131, §40
Appeals
The applicant, owner, any person aggrieved by this Determina-
Issuance of this Determination. A copy of the request shall at
tion, any owner of land abutting the land upon which the
the same time be sent by certified mail or hand delivery to the
proposed work Is to be done, or any ten residents of the city or
conservation commission and to the applicant If he/she is not
town in which such land Is located, are hereby notified of their
the appellant The request shall state clearly and concisely the
right to request the appropriate Department of Environmental
objections to the Determination which Is being appealed. To the
Protection Regional Office to Issue a Superseding Determina-
extent that the Determination is based on a municipal bylaw,
lion of Applicability. The request must be made by certified
and not on the Massachusetts Wetlands Protection Act or
mail or hand delivery to the Department with the appropriate
regulations, the Department of Environmental Protection has no
fling fee and Fee Transmittal Form (see Appendix E: Request
appellate jurisdiction.
for Departmental Action Fee Transmittal Form) as provided in
310 CMR 10.O3M within ten business days from the date of
Rev.10/98
BUILDING DEPARTMENT
CONSTRUCTION SUPERVISOR' FORM
PLE4SE PRIM.
job Location: t 7 A021FS 4 05
Number
Otvner of Property: MA24
Construction Supendsor.
Name
Address:
Licensed Designee:
(If other than Supervisor) Name
Street
S10
2.15 Responsibility of each license holder.
License No.
Village
License No.
—'?7D
Phone No.
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 drawins
as approved by the building official. g
2.15.2 The license holder shall be responsible to supervise the construction, reconstruction, alteration.
repair, removal ordemolition involving the structural elements of building and structures onlypursuant 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 subcontractor 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 willfullyviolate subsections 2.15.1, 2.15.2 or 2.15.3 oranyother 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, reconstruction,
alteration, repair, removal of demolition as regulated by section 109.1.1 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 department.
2.17 The license holder shall be responsible for requesting all required inspections. Failure to do so may
be deemed a violation of the permit conditions.
I have read and understand my responsibilities under the rules and regulations for licensing construction
sttperti isors in accordance with section 109.1.1 of the state building code. I understand the construction
inspection procedures and the specific inspection as called for by the building official.
INSURANCE COVERAGE:
I have a current liability insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.152
Yes @-' - No
If you have checked yU, please indicate the type coverage by checking the appropriate box.
A liability insurance policy Er Other type of indemnity ❑ Bond
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by
Chapter 15 of the
Mass. eneral Laws, and that my signature on this permit application waives this requirement.
��•// 11—� Check one:
of Owner or Owners
Owner ❑ Agent Q—
Signature:
Building Official Approval:
. .. 1
For Office Use Only E
Permit No.
Date TOWN OF YARMOUTH
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
MGL c. 142A requires that the `reconstruction, alteration, renovation, repair, modernization, conversion.
improvement, removal, demolition or construction of an addition to any pre-existing owner -occupied
building containing at least one but not more than four dwelling units or structures which are adjacent to
such residence or building' be done by registered contractors, with certain exceptions, along with other
requirements.
Type of Work: 3 J PQ&!fg E.t/c&asu2tF Est. Cost / 00. aD
AddressofWork 95 A02i5S A-j6 W-VARHOVEW.0 nA_ oz6?3
Owner Name: 13A28&Z� 9 VIAX—iOA77219l c
Date of Permit Application: G ^/5/-00
I hereby certify that:
Registration is not required for the following reason(s):
Work excluded by law
Job under $1,000
Building not owner occupied
Owner pulling own permit
Other (specify)
Notice is hereby given that:
OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH
UNREGISTERED CONTRACTORS FOR APPLICABLE HOME
IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION
PROGRAM OR GUARANTY FUND UNDER MGL'c. 142A.
Signed under penalties of perjury:
I hereby apply for a permit as the agent of the owner.
/z '!G
AcFdZD M RECA► GEft
Date Contractor Name Registration No.
• t_
Notwithstanding the above notice, I hereby apply for a permit as the owner of the above
property:
Date
Owner Name
Abutbor's
Name
Lot #
If this is a
corner lot,
write in name
of street.
x
;I
FOR LOT # a
Indicate location of garage or accessory building
Additions with dashed lines --------------------
Sewerage disposal (cesspool) ED
We-U 0
I
I(lot................ft. rear) I
3
2
�,�ccc�s� �x�sT��G �c►�� `�Y
wrrN 3 s�sotil
i�o2c 1 cN cCoSc2 REAR YARD
SIDE YARD
�]-- - - FT. 6%
.Q
SET BACK
60"s... Oft.
I
SIDE YARD
r
(lot.... 7Q........... ft. frontage)
�9 Ae2�s���WlaaHa�
(NAME OF STREET)
Information
Supplied by nCz2s lzo /an
MARK NORTH POINT
rC�
�REAMSPAC�
PATIO ENCLOSURES
Y
i
n
u
0
on
F O .G T P* .R 8 .N .T P R : ® G. R A V-? -
EKCLOSURE NUMBER: 3037- N
DEALER. BEST FIT WDW
CUSTOMER: KIRKPATRICK
N.LS.m "
m
HOUSEWALL
® Nod
M
0O0
m2
a
f
a
RIDGE BEAM 1�1 n
V1/2 X 166- " ®�
�o n
vI
0�
FOS1 AS$EMBL7 2 J/4"�EpVl3TEMPER D ILL FCLASS 113 7/8� 89 15/167
SIDE 2-143 3/4'
F O O T P R I N T
P R O G R A M
DREAMSPACP
PAT10 EBT MURES
•iY• Y.Y. arts tlYY11• .1�r1
R.
ROOF LAYOUT
HFfUSFWAL L
84 3/4" 04 3/4-
PANEL LENGTH PANEL, LENGTH
ENCLOSURE NUMBER: 3087 �i
OFq,�: BEST FIT r
Co
CUSTOMER: KIRXPATRICK
N.T.S.
at
HE
62.945 62.949
9.285 9.285
31.887 31.887
58.750 -- � �— M750 —
143.750
SIDE 2
(OLI)
r
N
10.000
INGING
(EIGHT
k (ZkPAT(2-lck
a,
6NDif. TO 1.6ck
I<Ic%k.
Sibs - ,3
600
ELMO;-
PRTIU DL)olt-
J
Z
P
gy.,g 1NG
1Ao%JSL
Industries, INC
To thalk it Key
RE1 io Roof
rl for your home."
301 Btushton Avenue
Pittsburgh, PA 15221-2168
(412)244-6400
FAX (412) 244-6496
t
ad Teat
August 13# 2993
Lowing c Went■ were atilised during the load tests$
IEEUP E 301s 4f'/X7=G Ht 2.5•LBS&I t4-•y?4 AL
MOJW 336j 366 OR 612
is KUJLNDED POLYSTYRENE 1.5f DEUSITY
x RUE >t .019" L .024' THIClto ALLOY 3003 H 14
! ORIENTED STMUD ZCMW 7/16' THICK
x EXTRUSI 1 $091 — T 6 ALLOT TREPIWMY BROKEN a KULLIOK
.050' wALL HAVING 3" WEB 6 3' TIANGE
WZjGHING c.6a3fIrT.
ullions aLre placed on the side of the test ;anal& and are attached to the panel
2" with 3 4" steel screw on the top only- i
alysis is based upon the experimental load testing results.as performed by our
employed inq our touts. The test procedures conform to the method described by
rican Zoe sty for Testing and Materials, Section E-721 `conducting strength Tests of
for xuild zq construction•- please rotor to that report for details of the teat
nt and me Zod used in our testing.
,sting was progressively conducted in accordance with these procedures to the load
noted. ads sustained for one hour and thenjreleased. UltiMAte load was not
mod boas. a the panels ware not tasted to failure.
w allowable superimposed live load
pounds per square foot with a factor of Safety - 2.5.
w
10� 67.9 pef
33� 48.9 paf
ISO 27.8 Pat
-WV1 Qi'T EDWARD J.
.1 9RCWN
.2 cmlL
thyagse ault ing D. 07697
Fclay
�FSS/pNAI EN
arr `own
OF VINYL FRAMED BUILDING PRODUCTS
3.1
F L81NUM6@�
EXPOSED
1,300 .400 1.300
.130
.342
.02S 1.245
cap
,01 OP.
1 .030 X to* IL2.34i .630
I.D' SYN
1.245
R (4)
.412
.250 .010 OP. 3iD
X 9(y .0=0
t 7 ttt7 R (4) .050
3.000 tt)
EXPOSED
T.6a0 340 1 .220
f•— R.070
.1es
.400 c101
tMMXZID I�ADU R.035 AREA OF POCKET.147
ALCoMRSAa UNu599nCM0 Uf43ftaA90WALL THCKUM
�' a '� Excel Extrusions Inc. ' wAlaay. p444a'E
�1.,,,
AknA di NJ rc MiERMAL INDUSMES F
.w
5566
ALLOWABLE SMESSES
-IAbi S 3100 Fb 2.0E
ffRBEAMSMOi TENEION C0111>RESSION nFt
rasuutroaaaw
F¢
3100
OE 31�)0- 2.0 2300 3180
Vafx
'
42' depth IFor other depth% adjust valve+ by (12/depth)% For depths leas than 5b". use the value for 5.5•.
Cr-LAM S 3100 Fb 2.0E SECTION PROPERTIES
MAXIMUM HEAR MOMEt1T�;INERTIA (� I Fl
om) ENT MAXIMUM
(Lb
1.1K
f!-it4
1i11a
1•tY.
2-�
31X
1.1Y+
2-a%
l•1Y+
1.1M
tau1-1%
311ri
r
l
14%
Al RR
I RR77 I
12SM
1 2452 1
4905 1
7355
55
111
188
3.63
7.26
10.89
8978
13967
120936
3214
6428
9642
1 125 j
250
1 375
14.76
9.51
J 14.27
9804
19209
28614
3806
7612
11418
207
415
622
5.63
12
j1d,
10637
21276
31912
4017
8035
12053
244
488
732
5.95
ii!#
14517
290.34
43551
4738
9473
14210
400
800
1200
7.01
14.0
15882137384
SMIS
6413
10826
16240
597
1194
1792
8.01
16.02
24
23337146674
70011
6090
121BO
18270
650
1701
2551
9.01
15.02
127.04
1K Patton:
k s%e% tined a for bending (Fb), tension (Ft), tromprnsian parallel to Erwin (Fc), sheer). atso maximum Momentand ' m shear values are for normal load duration. These may be increased where allowed by code for shorter bad durations.
F oast
For nat did bolts lnstalle perpendicular to the aide face of the beam. use National Design Spew%don (1991) Spruce • Pine - fir
vahus teral loads. F naUs Installed in the edge or narrow face of the beam parallel to the glue lines, use the code allowable
wlthd 'ues for lumWr havins a maximum specific gravity of 0.47.
I=:_�.
i�
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How besrhv e
1. the number of plies required for the Gan -Larn been and calculate the ma dmum reaction.
Y. th appropriate table for 1. 2 or-3 plies.
3. a length a maximum reaction that meets or exceeds your calculated value.
4. M lu the support Is eturally adequate to arty the reaction.
Aramp . 2 lice 1V+a" Gang- m LVL with s reaction of 9200 lb.
Selatfa : t w 3" beaftlength with a maximum reaction of 10710lb&
9.
I
6
E
ALLOWABLE ROOF LOADS (PLF) 125% NON -SNOW
17% 1 11i291i 1PhtihS3oli 1Ptytya11141Ph1P+211*A1 1PIy1Ks14 �fly1'
0 120 ss2 - 409 ON 722 608 722 a
7 lea 329 513 341 $17 US 2" 836 TI
e 114 247 3bS 237 $14 418 278 557 of
3 95 191 217 tee 398 322 214 429 &
2 T6 150 133 tee 311 293 102 337 4;
0 60 120 1 7 123 240 203 135 270 S
3 49 lie 1N 101 203 165 110 220 2'
0 4o eo 125 e3 1e7 130 90 181 2
0 34 67. 104 70 139 113 75 161 1
2 29 68 65 69 117 95 54 127 1
• 60 t00 61 64 106 1
4 43 8S 60 46 03 1
627 74 60 40 60 1
�t1 22 64 52 35 70
`1T 25 58 46 30 61
um msArnttin lmifonn load tables:
t the correet tasle for the beur. applicatlan
eed.
is the require beam span In the left column.
t a beam depth from the tables that satisfies
H the fire and I oW load PLF on the begin.
k the bearing r iquirtInClIft as shown on pale S.
I: Roof live lead 450 PLF. L/240 deflection EMIL
al load 675 PLF.IJ180 dellection iinilt.
pan 161. 04.115% snow lad
cTry 2 piles l 4 x 11W. which can early:
oad2x2U•19a450PLF ✓OK
toad 2 tt 953. 706 a 67S PLF ✓ OK
12
482
05
742
$22
$44
419
742
668
211
817
891
CM
911
817
10e3
967
1093
967
IM31WV
967
128
1-9
11,
3W
28D
C27
tie0
494
320
608
740
W
TO
1173
NO
873101310
224
182
440
365
395
322
264
114
527
429
648
S27
432
351
677
03
708
732
645
624
798
732
923
846
9
7
160
125
30a
250
285
221
177
147
353
295
434
302
2gg
241
677
483
"S
540
422
WO
S77
en
761
725
0
5
105
211
158
124
245
305
203
497
455
303
588
643
4
3
90
77
179
154
158
138
105
90
111
181,
259
222
1
148
$0
220
W
Ul
258
221
816
442
S61
472
3
60
133
117
78
150
192
128
258
257
191
392
406
2
55
116
102
58
138
161
111
223
249
186
332
355
2
51
101
m
59
119
14e
97
105
215
145
291
311
1
45
a9
79
82
105
129
U
172
192
128
250
273
1
39
79
89
ae
93
114
70
152
170
113
=7
242
1
190
190
31
63
6
37
74
012t
135
18-01
M92
1
Notes:
1. All beam spans shmm are clear spans and do not include
bearings.
2. 11use.tables are for simple spans (with a support at each
end) or for continuous (multiple span) beltrlls if spans
are equal
3. PLF values arc for a single ply of 1 tk• Gaag•laln WC
• Double the values for two plies.
• Triple the values (or three plies.
*4. For 14.• x le" beam%and deeper, two plies (rltitllmtml)
are requued.
S. More than three pries may requbv "ciat design. Contact
your LP engineered products distributor.
ALLOWABLE
ROOF
LOADS
(PLF) 115% SNOW
P41%17%
JP1y114291i
1Ph1K19%
1Pty1Y41IiY.
Iptir itIV1
1P1y114t14
1Ph114s18
1 1'y.218
IIL
WI
lb• LIN
Tao
Live tae
1101
lJw Leae
1M11
tang
Taal
offeWa1
Lai
DUfIYa!
We
leflw9u
teal
DafMcom
Lug
941WN
laY
swum
LW
Uwe
Dga•mMe
IN
Hato
Lin
41
NIIa
VIN
LINO
UM
t11I0
U140
WHO
dill
LR41
utw
WM
LR4
Law
tees
L/7e0
was
Wigs
Llaaa
tub
2
322
1226
554
430
43
W
W8
400
743
043
753
724
7108
750
OW
933
953
1023
1023
877
1023
1232
128212a2
1049
16W
1211
1555
311
1568
1311
te6e
1558
808
BM
1008
15W
66S
665
810
010
810
877
977
ion
1060
47
111
320
613
242
387
998
37a
686
718
615
711
760
724
768
947
$47
647
1122
132
1132
1334
334
1334
M
124
247
US
257
490
415
278
517
640
462
640
AM
544
8M
638
US
838
990
998
998
1187
1167
1187
43
05
121
297
198
396
322
214
420
534
35a
57a
615
419
615
751
088
751
889
IWO
689
1038
IOM
103E
11
73
150
2W
15e
311
253
leg
337
420
230
519
494
329
559
$51
691
=
W3
803
934
934
034
90
Co
120
187
125
249
203
135
270
SM
224
44a
396
254
499
523
432
623
722
545
732
849
649
849
73
49
lad
02
101
203
ta5
110
220
273
182
388
322
214
420
687
351
573
D73
524
873
778
747
778
60
90
83
le?
138
10
181
225
150
300
254
177
553
434
209
631
W
432
623
71e
815
715
80
.40
34
87
�25
04
70
In
In
76
131
tee
12S
250
221
147
905
W2
241
470
540
3W
$79
887
513
W7
42
28
60
Is
59
117
95
64
127
159
105
211
180
124
248
305
283
407
455
303
541
In
422
623
•
;70
50
100
81
64
104
133
90
179
158
105
211
250
173
346
357
250
492
651
W7
594
•
64
43
95
59
46
93
115
77
154
136
90
181
222
140
295
332
221
442
472
315
549
-
37
74
60
40
W
t00
Oe
133
117
70
138
lag
128
2M
987
191
3a2
400
m
509
•
e
32
64
52
35
70
87
se1
116
102
Oa
135
107
111
223
949
130
332
355
237
404
-
1
28
58
48
30
61
78
51
101
69
69
its
148
17
115
111
145
291
311
207
414
•
-
87
4S
89
79
32
105
129
06
172
122
128
258
273
182
385
•
-
69
39
79
e9
46
93
114
78
152
170
113
227
.242
181
323
•
}
-
53
35
70
82
41
e2
lot
e7
135
151
101
201
213
142
297
•
l
I I
47
31
63
55
37
74
90
ISO
135
90
18o
102
lie
256
41
A
gal4
33
e0
81
84
1
121
61
1 1
172
115
7W
7
i COUNTERFLASH
I
HANGING 'HEIOHT—
XABLE "F."
10 CHANNiL
ROOF; MNEL
I r�
TEK SCREW
--------------
II
I
II ,
9.767 —
7.159 —
i
i ra
6.175 x 2.500
ALUM. TUBE
i
1..WAkied ."r46e.r
REMOVABLE
TOPWALL "F" SECTION
1/2" x 9 1/2" GANG —LAM
POST "U"
POST "N"
L1Ja
THERMAL INDUSTRIES,
Brushton Ava.. Pitts rudd PA.npftu
pepe.ty Of 7we..ut lwmunMe lse.. �t /r*ttoeMen t+.tiibtue
GABLE RIDGE BEAM AND COLUMN FOR DS2000 3000
i°"n br-JAMI
0421 96
' x 0.33 1.ou &woes. VARIES
RBEAM.CWG
' 042000 11WO VARIES
"�`
The Commonwealth of Massachusetts
Department of Industrial Accidents
ON00011eresl/ISONs
600 Washington Street
Boston, Mass 02111
Workers' Compensation Insurance Affidavit
Inret inn•A 3 Wl/)rJ7Lvl L � -
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E1 am a hotfeowner performing all work myself.
1 am a sole proprietor and have no one working in any capacity
0 lam an employer pro%iding workers' compensation for my employees working on this job.
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:......�nee CO. policy 0
I am a sole proprietor. general contractor. or homeowner (circle one) and have hired the contractors listed below'aho have
the follo«in_,.%orkers' compensation polices:
company name,
address:
city
phone N-
insunnccCo
policy#
address,
phone N•
Insurance co eoflty M
JAI
Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of s fine ap to SIAN.00 and/or
oneyears' Imprisonment as well as civil penalties lathe form of a STOP WORK ORDER ands fine of S100.00 a day against me. f understand that a
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
t do hereby c ijy der the pa' it penalties ojperjury that the Information provided above Is true and eotreci
Signature -Pate /�
Print name h4nEhic oneA %--)
oRcial use only do not write in this area to be completed by city or town official
city or town: YARMOUT11
p check irimmediste response is required
contact person:
permitAicense N nBuilding Department
pllcensing Board
261 ❑Selectmen's OMce
phone M; pHealth Department _ i508) 398-2231 eat. bOther
tmned 3A5 P1A1
TOWN OF YARMOUTH
BUILDING DEPARTMENT
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT
DATE -!� �\1�3
JOB LOCATION R of Cam,,, VJ
NUMBER STREET
"HOMEOWNER"
PRESENT MAILING ADDRESS
ECTION OF TOWN
-7 I S-7A.S
PHONE WORK
TY OR TOWN II ST
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
ATTACHED 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 W�L CgTPLY WITi�A�D PPOCEDVP.ES AND REQUIREMENTS.
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING OFFICIAL
INSURANCE COVERAGE:
I have acurrent Insuran
❑ ce policy or Its substantial equivalent which meets the requirements of MGL Ch. 142.
es 0 NoIf you have checked Les, please Indicate the type coverage by checking the appropriate box.
A liability Insurance policy ❑ Other type of Indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by
Chapter 142 of the Ma s. Gene ws. and that my signature on this permit application waives this requirement.
eck one:
Owner Agent ❑
Signature of Q�wner ar ers A nt
Suggested Affidavit for Home Improvement Contractor Permit Application
For Office Use Only
Permit No.
Date
MGLe.14ZArequires that
orconstruction of an addit
to structures which are ad
i
requirements.
NAME OF CITY/fOWN
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
be done by registered oontnaors, with certain exceptions, along with other
Type of Work: ESL Cost
Address
Owner
Date of rermit t%ppucauon:
I hereby certify that:0
Registration is not required for the following rcason(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:
Date Contractor Name
OR:
Registration No.
Notwithstanding th a no , I hereby apply fora permit as t a owner of the above property:
Date Owner
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AGREE AVENUE
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