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Home My WebLink AboutBuilding PermitsGOWNER TYPE OR PRINT CLEARLY MASSACHLUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY LOW l� MA DATEPERMIT # _ JOBSITE ADDRESSI— Q[y1 OWNER'S NAME p (lc l u'Cl lt_ ADDRESS Iii( ,& I TE FAXI OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL NEW:❑ RENOVATION: El REPLACEMENT: f PLANSSUBMITTED: YES❑ NOD APPLIANCES 7 FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE 1' DIRECT VENT HEATER " DRYER I! FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE —6 - INFRARED HEATER r LABORATORY COCKS MAKEUP AIR UNIT E OVEN - POOLHEATER ROOM I SPACE HEATER nv ROOF TOP UNIT TEST 1 UNIT HEATER UNVENTED ROOM HEATER i ! WATER HEATER OTHER — i INSURANCE COVERAGE I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL. Ch.142 YES [!] NO ❑ I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY C] OTHER TYPE INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of.the Massachusetts General Laws, and that my signature on this permit application waives this requirement CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and Information I have submitted or entered regarding this application are true and ccurate t t best of my knowledge and that all plumbing work and Installations performed under the permit Issued for this application will be In complianc with I isio of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws, PLUMBER-GASFITTER NAME Joseph Ventresca LICENSE # 15742 SIGNATURE MP 0 MGF ❑ JP ❑ JGF ❑ LPGI ❑ CORPORATION �# 3255 PA RSHIP ❑#� LLC ❑#C_� COMPANY NAME:j South Shore Healing and Cooling ADDRESS 57 Whites Path CITY South Yarmouth STATE® ZIP 02664 TEL 508-398-6901 FAX 508-760-2681 CELL 508 360 5277 EMAIL oe@southshoreheatingcooling.com All4�v ROUGH GAS INSPECTION NOTES I THIS PAGE FOR INSPECTOR USE. ONLY Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT # PLAN REVIEW NOTES FINAL INSPECTION NOTES �'n'r� c�'�r3 c3� ✓Lr /4 (,5D kG-�7 �_ lccO,/�n�nwnusalEh o/�c/77/lals[Ca��s�a�.w JJrParlinanf of yira Jrrvicrl BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No.t'3� Occupancy and Fee Checked ev.1107J ocave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code Q� +52 04&12,00 (PLEASE PRINT IN INK OR TYPE ALL INFORAdmON) Datc: City or Town of: To the Inspector of Wires: By this application the undersign gives notice of his or her intention to p^rform the electrical work described below. Location (Street & u ber) ► r orTcnant r 1 J J v v Tclep one No. y_ q_g wn ® W tv w �-' 10 is Address s permit In conjuj&Lon ' with a bull ng permit? Yes ❑ No (Check Appropriate Box) ,� No. cv Thr se of Building W `Q YN 6 Utility Authorization V,J t` .--i O Is ng Scrvice Amps / Volts Overhead ❑ Undgrd ❑ No. of Metcrs V = _ ervice Amps / Volts Overhead ❑ Undgrd El No. of Meters (LJ Q 1P er of Feeders and Ampacity _ IX►on and Nature of Proposed Electrical Work: • __ r_.r __ _ r.r. _ r_ rr_...:_...,.1.I,. �.,... Ae .wAmd A. IAa /nrnortar n! rr/irPS. No. of Recessed Luminaires No. of CeB.-Susp. (Paddle) Fans 0. O Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool rnd e ❑ nnd. ❑ o. o mer enc n Batteryas Unity g g No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones 0. O e eetlon and No. of Switches No. of Gas Burner t Initiating Devices °m No. of Alerting Devices No. of Ranges Tons No. of Waste Disposers ea Totals um er 'ons ed Detection/Alerting lnDevices No. of Dishwashers Space/Area Heating KW Municipal Local 0 Connections Heating Appliances KW Secur ty ystems:• Devices E uivalent No. of Dryers No. of or o. of Water Heaters KW oo o. o Signs Ballasts. Data Wiring: No. of Devices or uivalent No. Hydromassage Bathtubs No. of Motors Total UP e ecommun ca ons r n : No. of Devices or Equivalent OTHER: GeAAv tha /narurlor ofWires. Estimated Valueectr I Work (When required by municipal policy.) Work to Start: 3 �2 inspections to be iequested in accordance with MEC Rule 10, and upon completion. INSURANCE CO ERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent The undersigned celtifies Oat such cov rage is in force, etn4 has exhibited proof of saaw to tht: permit issuing office. CHECK ONE: [NSURANCEI& BOND ❑ OTHER ❑ (Specify:) I certify, under the vain and vEnallies of perjury, that the Inform lion on this anon V true and complete. FIRM NAME:_ WAYNE SCHMIDT LIC. NO.: (p ELECTRICIAN Si nature'kJ LIC. NO.: �n �%�7 Licensee: 222 ONSWILLIMANTIC DRIVE g � 3 �// (Ijapplicab/e. enle. MARSTONS MILLS, MA 02648 r Bus. Tel. No.• Address: (508) 428.7747 All. Tel. No.• *Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" Licensc: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have tho liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) [] owner El owner's agent Owner/Agent Tcle hone No. PERMIT FEE: $ Signature P, . t,.. ��.T1211t,�': # iq?7 A�; "s 7 2012 �$ �D • lry BUILDING OEPT 1 V ZL�:J v: � Can Office Use Only !Permit# Fee S Permit expires 6 moolha from LSNi dale. � EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 261 CONSTRUCTION ADDRESS: OWNER: �l NAME *For, 61 •t Map: Parcel: / W 1\0.r cko,-�- 3 y 9 8ric1: PRESENT ADDRESS 8 Ct�w k_S 38s 4944, NAME v MA1llNGA RESS 0243/ -ILL# VRcsidential ❑ Commercial , / f Cost of Constructions / Or D O i'� a Home Improvement Contractor Lie. # l 3 Y �l0% ,ol ction Supervisor Lie. # / L7d J 5 5.1 Work-man's Compensation Insurance: (check one) I\ S ❑ I am the homeowner ❑ 1 am the sole proprietorKI have Worker's Compensation Insurance Insurance Company Name: Worker's Comp. Policy# WC-V 6 09 SU I ❑ Ted WORK TO BE PERFORMED (Fue Retardant Certificate suached) Duration ❑ Siding: # of Squares ❑ Replacement doors: Ka -roof. # of Squares 2Z Stripping old shingles* *The debris will be disposed of at: Wood Stove Shed ❑ Replacemed windows: # () going over layers of Hosting roof 1 declare under penalties of perjury that the statements herein contained are true and correct to the best of my knowledge and belief. I understand that any false answer(s) will be just cause for dcnW uLjevppatiogbf my liyjW and for prosecution under hLG.L Ch. 268, Section 1. Applicant's Signature: Owners Signature (or, Date: K) 7-_�_) Approved By-. Date: Building Official (or designee) Zoning Distric Historical District: Yes ❑ No Water R�s° Luce Protection District ,k Yes ❑ No Flood Plain Zone: ❑ Yes *0 Within 100 ft of Wetlands: t❑ No 3/01 r a1` Vie Commonwealth of llussachuselts Department ofhulustrialAccidents Office of Investigations 600 Washington Street Boston, AM 02111 www.mass.gov/dla Wnrkerss Cmmnensatinn Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Address: 10 2. c.J�'e.�su-.•O Phone #: Are you an employer? Check the appropriate box: 1. M T am a employer with 7 - 4. 0 I am a general contractor and I employees (full and/or part-time).* 2. ❑ I am a sole proprietor -or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.: 5. We are a corporation and its officers have exercised their right of exemption per MGL c. 152, §1(4), and we have no employees. [No workers' comp. insurance reauired.l Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition ME] Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *Any applicant that ehecl.•.s box 81 must"fill out the section below showing their workers' compcnsatioa policy information, t homeowners who submit this affidavit indicating they are doing all work Lnd then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub-cowracton Lad state whether or not those entities have employees. If the sub-conttutors have employees, they must provide their workers' comp. policy number. lam an employer that Is providing workers' compensation btsurance for my employees. Below is the policy and fob site Information. Insurance Company Policy # or Self -ins. Lie. #: i) Q D iv 0 S-0 1 Expiration Date:___5�� 201 1 Y Job Site Address: _m City/State/Zin \1a.A,'M Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in tier form of a STOP WORK ORDER and a fine. of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. --------- -- -- I do hereby cpti y ;0de(jjthe pajitAand penalties of perjury that the information provided above is true and correct. Ehoned: SD8 saS— 61S-q� Officlal use only. Do not write In this area, to be completed by city or town official. City or Town: .Issuing Authority (circle one): Permit/License # (;11S/ 4) 1. Board of health 2. Building Department 3. City/Tomm Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone #: 08/22/2010 10:35 FAX 6174886501 UNDERWRITING IM001/002 I pI mmgmr.rr� 612212010 PRODUCER IRODUiCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Kerry Insurance Agency, Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR PO Box 1945 ALTER THE COVERAGE AFFORDED BY THE POLICES BELOW. COMPANIE8 AFFORDNNO COVERAGE North Eastham, MA 02651 COMPANY A Atlantic Charter Insurance COmDanV VDAC COMPANY wiURED Robert Chambers, Inc. 0 COMPANY 102 WhiMetree Avenue C COMPANY Brewster, MA 02631 0 NIL LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERNOO THIS IS TO CERTIFY THAT THE POUCIES OP INSURANCE ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT wNTH RESPECT TO WHICH THIS INDICATED. NOTIMTHSTANDING MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, CERTIFICATE EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO TYPE OF INEURNICE POLICY NUMBER POLICY EFFECTIVE DATE BArLIDDII'1T POLICY EIIDRATON DATS(MWODIYYI LIMITS on TM.+AnAA) LTR BODILY INJURY OCC i GENERAL LIABILITY BODILY INJURY AM i COMPRF.IF.NAVS FORM PROPERTY DAMAGr OCC i ►REMSESIOPERATIONS PROPERrr DAMAOEAGG i UNDERGROUND BI A PD COMBINED OGG M EII►LOEION E COLLAPSE HAZARD MEPO COMBINEDAGG i PROOUCT&COIAPLKTM OPER PERSONALIRIURY AGO s CONTRACTUAL INDEPENDENT CONTRACTORS BROAD FORM ►ROPI DAMAGE PERSONALINJURY AUTOMOBI E LIABILITY BODILY INJURY ANY AUTO (pc peman) i BODILY INJURY ALL OWNED AUTOS (PI PI ALL OVNFD AUTOS (PWAI i (OWW BWI PMab Nuonpm) HIREOAUTI PROPERTY DAMAGE i BODILY INJURY A NON-CMEDAUT04 GARAGE LIAMiJTY PROPERTY DAMAGE COMBINED i EiCEiE L1AMLm EACH OCCURRENCE i AGGREGATE i UMBRELLA FORM i OTHER THAN UMBRELLA FORM A 100ORIGMCOWENEA71°NA"B WCV00609505 1/292010 1/29/2011 X STATLRORYWNTS EACH ACCIDENT s 100.000 BMPWYR 1IMAI^r ' DISEASE• POLICY LIMIT / 500.000 DISEALTE•EACHEMPLOYEE i 100,000 OTHER 0E3CRlT100 DP OPERATIONULOCA7IDIYIFENI LENPECIAL RELY pul " 1 AeE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE Town of Yarmouth Building Department EXPIRATION DATE THEREOF. THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 1146 Rome 28 12 DAYS WRITTEN NOTICE TO THIS CERTIFICATE HOLDER NAMED TO THE LEFT. South Yarmouth, MA 02664 BUT FAILURE TO L SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UP E COMPANY. rrs TS OR REPRESENTATIVES. AUTNonNUD REr ft9 WADI �� -III, w r TOWN OF YARMOUTH Building Department BUILDING �!! _ . _ _ _ . _ _ _ , (508) 398-2231 ext.261 � PERMIT NO �_ B-10-1493 _- PERMIT �.. ISSUE DATE ;. 6/ =010. ; PROPOSED USE APPLICANT bob Chambers'""""" """" JOB WEATHER CARD PERMIT TO Repair AT (LOCATION) 10008MERCHANT AVE ZONING DISTRIC R-40 Bldg. Type: Residential SUBDIVISION MAP LOT BLOCK 1127.17 BUILDING IS TO BE: CONST TYPE EB- USE GROUP R-3 LOT SIZE I I strip and reroof, 22 squares, paper and vent to code REMARKS AREA (SO FT) EST COST ($ $10,000.00 OWNER IGARCIA, ROBERT EDWARD ADDRESS 10008 MERCHANT AVE Yarmouth MA 102664 PERMIT FEE ($) $70.00 BUILDING DEPT BY INSPECTION RECORD CONTRACTOR LICENSE CSSL 100134 Chambers, Robert 102 WhiHletree Ave Brewster MA 02631_ 5083854546 PHONE 15083949886 FIELD COPY Date I Note Progress - Corrections and Remarks I Inspector &A a r TOWN OF YARMOUTH Building Department BUILDING (508) 398-2231 ext.261 '- PERMIT NO �- 6-07-1504- � PROPOSED USE PERMIT •. ISSUE DATE ;. 6/28/2007 - ; APPLICANT .'Robert Garcia ............................. - JOB WEATHER CARD PERMIT TO %Accessory Structure AT (LOCATION) ZONING DISTRIC R-40 Bldg. Type: Residential 10008MERCHANT AVE SUBDIVISION MAP LOT BLOCK 1127.17 BUILDING IS TO BE: CONST TYPEFEB-] USE GROUP R-4 LOT SIZE O 8 x 12 shed - subject to zoning bylaw setbacks REMARKS AREA (SO FT) EST COST ($ $1,000.00 OWNER IGARCIA, ROBERT EDWARD ADDRESS 10008 MERCHANT AVE YARMOUTH I MA 102675 _ BUILDING INSPECTION RECORD CONTRACTOR LICENSE 0 PHONE 15083949886 w FIELD COPY Date 1 „ IA4ofe Progress - Corrections and Remarks I , Jnspector in r PERMIT 18 LOT 1& Garcia, Robert 8 Merchant Avenue Yarmouthport, MA 02675 1/8/99 1/8/99 Wood stove (used) $100.00 SHEET 127 M CONSTRUCTION ADDRESS: 8 M F- iZ G H A uT A V E u u g, / � ASSESSOR'S INFORMATION: SHEDS LESS THAN 150 SQ. FT. SHALL BE PLACED A MINIMUM OF 30 FEET FROM THE FRONT LOT LINE AND A MINIMUM OF 6 FEET FROM SIDES AND REAR LOT LINES, EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 ro South Yarmouth, MA 02664 (508) 398-2231 Ext. 261 JUN 2 8 Office Use Only Permit # i Fee S� Permit expires 6 man from issue date. E I V E D BUILDING DEPL By: -- Map: 127 1 Parcel: 17 OWNER: Ro6ERT V.• L7tAeG1A 8MEeciAmaT A-iis. 508- 394-9686 NAME PRESENT ADDRESS TEL # CONTRACTOR: OUIME R SAtAE SAME NAME MAILING ADDRESS TEL.# Aesidential ❑ Commercial Est. Cost of Construction S I _0 00 . Home Improvement Contractor Lie. # Construction Supervisor Lia # Workman's Compensation Insurance: (check one) ❑ 1 am the homeowner 0 I am the sole proprietor 0 1 have Worker's Compensation Insurance Insurance Company Name: Worker's Comp. Policy# WORK TO BE PERFORMED 0 Tent (Fire Retardant Ca"cate attached) t Duration Wood Stove Shed 8 X I Z ❑ Siding: # of Squares ❑ Replacement windows: # ❑ Replacement doors: # 0 Re -roof # of Squares () Stripping old shingles$ () going ova layers of existing roof *The debris will be disposed of at Location of Facility I declare under penalties of petjury that the statements herein contained are true and correct to the best of my knowledge and belief. I understand that any false answer(s) will be just cause for denial or of my license an or prosecution undo M G.L Ch.268, Section i. Applicant's Signature: Date 6/ 27107 Owners Signature (or attachment) Date: in l 27 / d % Approved By. Date: Building Official (or designee) Zoning District:�4 a , Historical District: Kyes ❑ No Flood PWn Zone: ❑ Yes No Water urce Protection District: Within 100 R of Wetlands: JNYcs 0 No es ❑ No 3101 f The Commonwealth of Massachusetts -' .. Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ig bly Name (Business/Organization/Individual): Address: ]� h-*` j' '✓y"�— �b City/State/Zip: Phone #: Are you an employer? Check the appropriate box: ❑ 1. ❑ 1 am a employer with 4. I am a general contractor and I employees (full and/or part-time).' 2. ❑ I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance trequired.] ] I am a homeowner doing all work yself. [No workers' comp. insurance required.) t have hued the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.= 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' come. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling S. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions I I.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other--c 'Any applicant that checks box # 1 mist also fill out the section below showing their workers' congwtsation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such tContraotors that check this box mist attached an additional sheet showing the name of the subcontractors and a= whether or not those entities have erriployccs. If the subcontractors have employees, they must provide their workers' comp. policy number. I am an employer that Is providing workers' compensation Insurance for my employees. Below is the policy and Job site Information. Insurance Company Name: Policy # or Self -ins. Lic. M Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to S 1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of _ Investigations of the DIA for insurance coverage verification. I do hereby eerp)A' under the pains aAd penalties of perjury that the Information provided above is true and correct Phone 4- use City or Town: area, to be completed by city or town official. Permit/License # m6� Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person• Phone #: Information and Instructions _ Massachusetts General Laws chapter 152 requires all employees to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the Issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the Insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for, the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self -insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-7274900 ext 406 or 1-877-MASSAFE Revised 11-22-06 Fax # 617-727-7749 www.mass.gov/dia r PLOT PLAN FOR LOT Dd3Cate J=ation of garage or accessory building Additions with dashed lines ------------------- Sewerage disposal (cesspool) ® . Mall I I(yJb................ft. rear) I r1 butb='s ame ot# = this JS a = ner tatv rite in name atxaet. SIDE YARD -- - -xr-1. Q I 1 REAR YARD 1 SMZ YARD I SET BACK . I (lot..................ft. frontage) (NAME OF STREET) �. Information Sunnited by TOWN OF YARMOUTH 1146 ROUTE 28 SOUTH YAR.\IOUTH INL\S.SACHUSETTS 02664 7ekphone (508) 398-2231 r-j OLD KING'S HIGHWAY REGIONAL HISTORIC DISTRICT COUJII7DTE �D CERTIFICATE OF EXEMPTION ' m Application is hereby made for the issuance of a Certificate of Exemption under Section 6 —and 7 of Chaptet470, Acts and Resolves of Massachusetts, 1973, as amended for proposed work as describqdll elowpand � ghdns, drawings, or photographs accompanying this application.. o 2� TYPE OR PRINT LEGIBLY DATE 5 1 Z (` a7 ADDRESS OF PROPOSED WORK a ME EC to!J v Ay E N u e ASSESSORS MAP # 1 Z7 OWNER RoBEILT SUb t*rt4 GARCIA ASSESSORS LOT#17 HOME ADDRESS 8 MEacytAmy ikyekuE TELEPHONE#50$'394-98BC AGENT OR CONTRACTOR 0 W ME Z ADDRESS S /! A E TELEPHONE # THIS APPLICATION IS FOR EXEMPTION OF PROPOSED EXTERIOR CONSTRUCTION ON THE GROUNDS THAT: ( ) IT WILL NOT BE VISIBLE FROM ANY WAY OR PUBLIC PLACE. (a.)' IT IS WITHIN A CATEGORY DECLARED ENTITLED TO EXEMPTION BY OLD KINGS HIGHWAY REGIONAL HISTORIC DISTRICT COMMISSION. (Check applicable boi) PROPOSED WORK: DESCRIBE WORK, SHOWING LOCATION ON LOT, AND, IF AN ADDITION IS INVOLVED, SHOWING LOCATION OF EXISTING BUILDING. 8'x Is' 1 APPRO�, ED � ��• - MAY 44 2007 YARMOUT8 Signed KINO'S FIIGHVv,4y —�0Owner - Cont tor- Agent Space below for Committee use. Received by OKHC Date q?,110-1 Check# Caaj - By APP OVED( ) DENIED ( ) The certificate is hereby /Z�� 40�7�`-' G(9 " a' o Date �/� �� Prin4A ,n Racyclud P iper oosT� Si' OARAGE PLOT PLAN 8 MERCHANT AVENUE MAY 19.2007 caAPHE scus (wpm) 1r -m s WA A.M.127-16 ROBERT HARDR A.M.127-17 LAWN PATJ\ Yoc� A.M.127-18 FRED & MARTHA PATIO DLSON MERCHANT AVENUE 00005RE0WoME H 0 a MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Frint or Type) u , Mass. City, Town Renovation El Plans Submitted Yes ❑ No tea, Date�� Permit _ 03- GJ / Owner's O I Name Type of Occupancy:_ Replacement D--� y ¢ 412 �K \ Us y 2 C N t�\yd. ram` cc cc ¢ y ~ It N' J y cc W h 0 61 ~ = y 2 O W t¢ el = W Gl ¢ m W< W W h0. y C. ¢ W < v' ¢ O ccW W y ¢ U1 a X< p. 2 W j h <¢ Y 1.. M W 3• to O a3 A Z 4. O h Z¢ W J O y S ¢ W 2<¢``< 3 tl 0 0 W O W h O r 0e S 10 O Y W 7 G J V ¢ Y O O. h SUB=BSMT. BASEMENT 1ST FLOOR 4NDFLOCR 3RD FLOOR 4TH FLOOR 5TH FLOOR BTH FLOOR 7TH FLOOR BTH FLOOR (Print or Type) Check One: �� Certificate Installing Company Name �!![ 9%Utd/� WN -0 &-AW1 4r RL Corp. OIL v '�,5 Address ❑ Partnership ❑ Firm/Company Business Telephone) Yin *z yY / / Name of Licensed Plumber or Gasritter ,l�iNsLDU% Z I hereby certify that all of the details and information 1 have subn, tted (or entered) in above application are true curate to the bat of my knowledge and that all plumbing work and installations performed ur er Permit issued for this application wi m eompla with all pertinnt provisions of the Massachusetts State Gas Code and Chapter 142 of th, General Laws. I have infotm:d the owrer or his agent that I do not have liability imurantx including completed operatio covcra, -n Siptat= of 0wWj Mein 1 have a current liability insurance policy to include completed operations coverage. IR'F By Title City; Town APPROVED (OFFICE USE ONLY) ❑ Plumber �,�..o...................._.. Plumber or Gasritter ❑ Gasritter �'�� / ,� WMazter —.-- _ 0 Journe)man License Numtcr FINAL INSPECTION SKETCHES BELOW FOR OFFICE USE ONLY PROGRESS INSPECTION FEE NO. APPLICATION FOR PERMIT TO DO GASFITTING NAME A TYPE OF BUILDING LOCATION OF BUILDING OR GASFITTER LIC. NO. PERMIT GRANTED DATE 1y__ GASINSPECTOR TOWN OF YARIMOUTH Building Department Town Hall YwnmM, AAA 02664 . (-%8) 398-2231 eA.261 Building Location: Owner's Name: Owners Address: Owners Telephone: Gasiitter Name: License Number. Company Name: Company Phone: PERMIT TO DO GASFITTING WORK (OFFICE USE ONLY Recorded By: PERMIT NO. Permit Fee: Payment Type: Check Number. `.----- ---- ____-- Issue Date: 1 Type of Work: Comments: INSPECTION RECORD Date Note Proaress - Corrections and Remarks inspector C` Date Pointed: 5/16102 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Print or Type) AT: New — �klwhl�b , Mass. City, Ton _ Building I nnatinn Date �� -le 5 t� a�na- Permit li P— 6�3— Type of Occupancy:_ Renovation ❑ Replacement. FIXTURES Plans Submitted Yes ❑ No MMomoomumo■��000n ��monumon�oonn�� mmoomo�no�uno NNNNENNONE �nnnnmmnnnnmm (Print or Type) Installing Company Address Business Telephone H O a a a Check One: Certificate ■ ■ Corp. Oynz$W �I F Partnership Firm/ Company Name of Licensed Plumber or Gasfitter JEEP. Or. - I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit issued for this application will be in compliance wi all pertinent provisions of the Massachusetts State Gas Code and Chapter I42 of the General Laws. 1 have informed the owner or his agent that 1 do not have liability insurance includink1%;4 d ons cov rase. signature of Ownerl Agent I have a current liability insurance policy to include completed operations By Title City; Town APPROVED (OFFICE USE ONLY) pe of Plumb' License License License Nuumbmb L+7 r Master ElJourneyman er NAL INSPECTIONS SKETCHES BELOW FOR OFFICE USE ONLY FEE NO. APPLICATION FOR PERMIT TO DO PLUMBING NAME 1 TYPE OF BUILDING LOCATION OF BUILDING PLUMBER PERMIT GRANTED DATE 19 PLUMBING INSPECTOR PROGRESS INSPECTIONS d TOWN OF YARMOUTH o � Building Department Town Hall O,. Yamvith, MA 02664 (coal 3G&2231 eA261 Building Location: Owner's Name: Owner's Address: Owner's Telephone: Plumber Name: License Number: Company Name: Company Phone: ; PERMIT TO DO PLUMBING WORK (OFFICE USE ONLY Recorded By. PERMIT NO. Permit Fee: Payment Type: _ Check Number.' Issue Date: Type of Work: Comments: INSPECTION RECORD Date Note Progress - Corrections and Remarks Inspector Lf — 16 - oz, I F1I19 LAA -C . -NY] ,s7 ! i-r, Pei 1 r)nto Printod- Allrino TOWN OF YARMOUTH o Application for a Permit to Build No. FMLY 114 --rz3 UPON FINAL APPROVAL P� / �� MAP 127 LOT FEE MUST ACCOMPANY THIS APPLICATION. DATE 19 The undersigned hereby applies for a permit to build according to the following specifications 1. Name of property own( Addres 2. Name ofArchitect (if any) 3. Name of builder Address 4. License No, Tel, 5. Name of Mason Address 6. License No. 7. Construction address 8. Date of subdivision Approval Tel, 9. Private dwelling ❑ Estimated Cost 10. Multifamily ❑ Q 11. Commercial ❑ 12.Other ❑ 13. No. of stories 0 VE 14. Foundation — Full ❑ Half ❑ Crawl ❑ Slab ❑ 15. Materials — Wood ❑ Cement ❑ Other ❑ 16. Type of heat — Oil ❑ Gas ❑ Electric ❑ Other ❑ 17. Garage —1 ❑ 2 ❑ 18. Swimming pool - Size 19. Storage shed — Size 20 tove — Wood VCoal 21. Size of lot: No. of feet front No. of feet rear Tel. 314 -9 a8� Tel. G District Zone �- 4-o DO NOT WRITE IN THIS SPACE Type of room I No. fl A-6-6 Kitchen Dining Rm. Living Rm. Bed Rm. Bath Deck Closed porc Family Rm. Sun room Shed Alterations 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 Side line 25. H.I.C.R. No. LOT RELEASED BY Signature ja PLANNING BOARD Address 8 ME QCHANT Ay6 _ Date yAen+ouTH MA 07-G75' VI II...two I%&.iV 1 Permit A wilding permit is recuired for the Installation of any solid fuel burning appliance. The building permit and installation inspection are limited to the stove installation and not to the stove construction. Stove A. New se B. Typeiraeiant RAbiweir I aura C. Manufac:urer Alb NAbty- I =No. Namer Mcce! No. Collar size 8 'r Gimensicni"Heicht 240 i angtn 34) Chimney A. New g�j CYi�y lSdoc. size (tlue area) » C. Other appliances attached to flue (Numaer and flue size) 0. P.efat:(Manufac:urer—nameand type) �. ,LlascnryiLined Cuolnnr YES Uniinee gyoa • manuwacweri F.: ieight (refer to ciagr ams) can 5M%19ML7 okL '1wV'1,1,V Hearth Iron-:cr..a�s»stet A. Matena!s o. Suc-kcr=nst,.:r'cn CONGRGTE :.. Minimum eimersicrs irefer:a wacra,-ri CIearancas ana Wail Pretec:icn isee stove irstailaucn c_arancas cnartl A. Type .t'uail crctec-cn crcvicea 9. CtaWaricesirefermri agramst C7j C@iIMNEY i iEiCr i r MF;E=LaCE CORNER WALLICENTER TOWN OF YARMOUTH Application for a Permit to Build UPON FINAL APPROVAL 7�10 y� MAP 1 14 LOT 23 FEE MUST ACCOMPANY THIS APPLICATION. DATE /�19 9 The un eisigned hereby applies for a permit to build 7y)Ile acco ing to the following specifications Name of property owner Ro 8E r E.. G Atzc q Address 8 MF.rzcKAuT AVF-MU9- 2. fame of Architect (if any) �./Name of builder Roaex-r GABFtA - cwMF 3- Address _ o " V4-A� o K r-r:w 5/15A9g 4. License No. Tel. 5. Name of Mason Address License No. Tel. . Construction address 8 ME-RCH At4T A,yE11uE E: ..4 No. °Z 3 / Tel. 394-9 986 Tel. 8. Date of subdivision Approval plain zone C Zone V� R- 40 9. Private dwelling ❑ Estimated Cost DO NOT WRITE IN THIS SPACE 10. Multifamily ❑ Tf j 6. .Type of room No. 11. Commercial ❑ LQ�/(/,j�2 Living Rm. Kitchen 12.Other Dining Rm. �y v � 13. No. of stories tf x /� 5 , cID Bed Rm. 14. Foundation — Full ❑ Half ❑ Crawl ❑ Slab ❑ Bath 15. Materials — Wood ❑ Cement ❑ Other ❑ 16. Type of heat — Oil ❑ Gas ❑ Electric ❑ Other ❑ Closed porch 17. Garage —1 ❑ 2 ❑ Family Rm. Sun room 18. Swimming pool - Size Garage 19. Storage shed — Size Shed 20. Stove — Wood ❑ Coal ❑ Alterations 21. Size of lot: No. of feet front No. f 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 F om rear lot line 25. H.I.C.R. No. LOT RELEASED BY PLANNING BOARD Date Signature /—a;b EJ 0 Side line Address 8 MERCHANT AVENUE `(ARNtourN MA O 2676 BUILDING PERMIT APPLICATION SIGN OFF APPLICANT: aSEP-T E_. QAP-C /A BUILDING PERMIT #: ADDRESS: S ME?_G"AM-r AVE. . VARMouruTELE. NO.: 394-9886 DATE FILED: BLDG. SITE LOCATION: SA ME MAPh ri4 LOT#: T 2.3 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: WATER DEPARTMENT: ENGINEERING DEPARTMENT: CONSERVATION COMMISSION: HEALTH DEPARTMENT: FIRE DEPARTMENT: RESIDENTIAL AND/OR COMMERCIAL BUILDING DETERMINES COMPLIANCE OF WATER AVAILABILITY. DETERMINES COMPLIANCE FOR PARKING AND DRAINAGE. DETERMINES COMPLIANCE TO WETLANDS ACTS, I.E.: IF LOT(S) BORDER ANY TYPE OF WETLANDS, STREAMS, PONDS, RIVERS, OCEANS, BOGS, BAYS, MARSH LAND, ETC. DETERMINES COMPLIANCE TO STATE AND TOWN REGULATIONS, I.E.: REQUIRE- MENTS FOR SEPTAGE DISPOSAL AND OTHER PUBLIC HEALTH ACTIVITIES. DETERMINES COMPLIANCE TO STATE AND TOWN REQUIREMMTS 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: REVIEWED BY: 1. WATER DEPARTMENT DATE: N/A: 2. ENGINEERING DEPARTMENT: DATE: N/A: 3. CONSERVATION: DATE: N/A: 4. HEALTH DEPARTMENT Via,/,� . - _ DATE: N/A: INDUSTRIAL AND/OR COMMERCIAL PERMITS 5. 6. 7. WIRING INSPECTOR: _ PLUMBING INSPECTOR• FIRE DEPARTMENT: PLEASE NOTE DATE: N/A: DATE: N/A: DATE: N/A: 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: BLM 89 TOWN OF YARMOUTH BUILDING DEPARTMENT HOMEOWNER LICENSE EXEMPTION PLEASE PRINT: DATE 4-1 15' 9 8 JOB LOCATION $ MERCHAAIr AvE. STREET ADDRESS "HOMEOWNER" Ko4ER.T t.-QihzciA 394-96810 NAME HOME PHONE PRESENT MAILING ADDRESS 8 Meecu Atux Ave, kZMOt.1TR CITY OR TOWN 6UTK ON OF TOWN 98 - 2231 Exr. 25a WORK PHONE OZ675 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 WILLOIMPLY WITI SAID PROCEDURES AND REQUIREMENTS. HOMEOWNER'S SIGNATURE / GaA /. r�r _ A a APPROVAL OF BUILDING OFFICIAL INSURANCE COVERAGE: I have acurrent liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes ❑ ❑ If you have checked Yves. 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 Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner ❑ Agent ❑ Signature of Owner or Owners Agent The Commonwealth of Massachusetts Department of Industrial Accidents exce 9/1" ffliffoss 600 Washington Street Boston, Mass. 02111 Workers' Compensation Insurance Affidavit � u C.; ►I C G 530`I am a homeowner performing all work myself. ❑ I am a sole proprietor and ha%e no one working in any capacity am an employer pro► iding workers' compensation for my employees working on this job. insurance co policy # I am a sole proprietor. general contractor, o omeowne circle one) and have hired the contractors listed below who ha%e the followin_ workers' compensation polices: Failure to secure coverage as required under Scctioo 25A of MGL 152 can lead to the imposition of criminal penalties of a (Inc op to 51.500.00 sad/or one years' Imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a flue off100AS a day against me. 1 anderstand tint a copy of this statement maybe forwarded to the Office of Investigations of the DU for coverage verification. I do hereby cen • under the pains a d penalties of perjury that the information provided above is true and correct. SignatureDate T 9>3 Print name ROBERT E. OnARCIA Phone# 394- 98860 I fficial use only do not write In this area to be completed by city or town oflkial city or town: YARMOUTIL check if Immediate response is required contact person: permitAiceuse 0 nBuildiog Department E3uceosfog Board 261 OSeleclmen's Office ❑Hulth Department phone#;_ (508) 398-2231 eat. riothcr 0n .sed )M P1A1 Information and instructions Massachusetts General Lays chapter I52 section 25 requires all employers to provide workers' compensation for their entplo%ees. As quoted from the "la%+•", an employee is defined as every person in the service of another under any contract of hire, express or implied, oral or written. An entph!rer is defined as an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise. and including the legal representatives of a deceased employer, or the receiver or trustee of an individual . partnership. association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance , construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter I5=section =: also states that even• state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any vidence of compliance with the insurance coverage required. applicant who has not produced acceptable e Additionally, neither the commomvealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter ha%e been presented to the contracting authority. .applicants Please till in the workers' compensation affidavit completely. by checking the box that applies to your situation and suppling company names, address and phone numbers as all affidavits may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested. not the Department of Industrial accidents. Should you have any questions regarding the "law" or if you are required to obtain a workers' compensation policy. please call the Department at the number listed below. City or Towns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to sill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference ntunber. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. The Office of investigations would like to thank you in advance for you cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number. The Commonwealth Of Massachusetts Department of Industrial Accidents trace of lalrottllrilel 3 600 Washington Street Boston, Ma. 02111 fax N: (617) 727-7749 phone #: (617) 7274900 ext. 406, 409 or 375 Suggested Affidavit for Home Improvement Contractor Permit Application For omce use only NAME OF CITY/TOWN Permit No. Date AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application MGLe.141Arcquires that the 'reconstruction, alteration, renovation, repair, modernization, conversion, inyrcwement, removal, demolition, or construction of an addition to anv ore-mistint owneroccunied building contain ineat least one but not more Ihan fourdwelline units .... or to structures which are adiacent to such residence or building" be done by registered ebntractors, with certain exceptions, along with other requirements. Type of Work: Butt_D # PIA41SH WALLS Ihi BASEMGMT Est. Cost 900.— Address of Work 8 McReHAwr Avg. t YARMourH . MA 0Z(675 Owner Name: RoBF-tT E. GARCIA Date of Permit Application: 4' I hereby certify that: Registration is not required for the following reason(s): Work excluded by law Job under S1,000 Building not owner•occupicd /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 Registration No. OR: Notwithstanding the above notice, I hereby apply for a permit as the owner of the above property: 4 IS 9 O&Ltr 4A.r'. Date Owner Namc U O i 0 UNFINISHED 5TORAGE AREA J J _ Q J 3 w A � 0 z 3� FURUACE Noo z FIAIJSH CONC. BLOCK %v/571RAPP(NG f SHEETR05 r N GAME ROOM I m 24.-p„ • > I r— %"/5T IPOURED CONE. WALL STRAPPING $ SNt:ETROCK I • • a BASEMENT PLAN S MERCHANT AVENUE SCALE: l"= 5' THE COMMONWEALTH OF MASSACHUSETTS 183 Fee.........J...... TOWN OF YARMOUTH No....................... '3 OCCUPANCY PERMIT "No building nor structure shall be erected, and no land, building or structure shall be used for a new, different, changed, or enlarged use without a Building Permit therefor first having been obtained from the Building Inspector. No building shall be occupied until a certificate of occupancy has been issued by the Building Inspector:' % 4 i A n n . - Issued to Wiring Inspecto .... .. .............. Jfis fiction Date.....abll�l..Cr........ P Plumbing Ins .. . .....................Inspection Date.....�r...:.��.... Fire Department ...?al. Inspection Date ...... ?//I41�b. Building Inspector.. G .....fir.'!/ ...��...'............................inspection Date..V11&-1z64 Assessors...................................................................................inspection Date......................................... THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE TH TOWN REQUIREMENTS. a L . Date:. Building Inspector....... ........... ��.............. TOWN OF-YARMOUTH a � APPLICATION FOR PERMIT TO DO GASFITTING (OFFICE USE ONLY) By C Fee: $ °� S PERMIT NO. (9"< Date Building /- Owner's /1 0 - . AT- Location r�IF,r�h A Ire Name k7) ArG _1q yArmdot p Type of Occupancy New ❑ Renovation ❑ Replacement ❑ Plans Submitted Yes ❑ No ❑ el N Y w Cn co N w co ¢ Z M IL y e: N O 0 Y m H Z rn cc WCl) m H w w o rn m w Lu a W Q x Z f. m 0 > W 7 W M N W Z Q= M _ = w 0 �". x N Q O Q Q 2 WUJI = a m W M W> x 0 0 x LL Z 0 3 o>G c Q 0 g 0 U¢> 0 W¢ c O o. f- o SUB-BSMT. BASEMENT 1ST FLOOR 2ND FLOOR 3RD FLOOR (PRINT OR TYPE) I Installing Compa Name 1 f "Aq Address 1 In Business Telephone Name of Licensed Plumber or Gasfitter k AM /rayN C1 INSURANCE COVERAGE: Check One: ❑ Corp. ❑ Partnership ❑ Firm/Company Check One have a current liability insurance policy or its substantial equivalent. Yes ❑ No ❑ If you have checked yes, please indicate the type of coverage by checking the appropriate box. A liability insurance policbj � 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 Mass. General Laws, and that my signature on this permit application waives this requirement. Check One: Owner ❑ Agent ❑ Signature of Owner or Owner's Agent 1 hereby certify that all of the details and information I have submitted (or entered) In above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Signature of Licensed Plumber or Gasfitter ,37y4 License Number TYPE LICENSE: ❑ Plumber O Gasfitter []Master []Journeyman TOWN OF YARMOUTH s Building Department Town Hall Yarmouth, MA 02664 (508) 398-2231 ext.261 Building Location: 00008 MERCHANT AVE Owner's Name: ROBERT EDWARD GARCIA Owner's Address: 00008 MERCHANT AVE Owner's Telephone: Gasfitter Name: License Number: Company Name: Company Phone: Yarmouthport MA 02675 Traynor, Adam 3740 Cape Cod Gas Heat (508) 539-9303 PERMIT TO DO GASFITTING WORK (OFFICE USE ONLY Recorded By: Ic PERMIT NO. G-03-574 Permit Fee: $25.00 Payment Type: Check Check Number: 1040 Issue Date: 1/16/03 Type of Work: Renovation Comments: gas log INSPECTION RECORD Date Note Progress - Corrections and Remarks Inspector 0 Date Printed: 1/17/03 PERMIT 231 4/15/98 4/15/98 LOT T23 Garcia, Robert E. 8 Merchant Avenue Yarmouthport, MA 02675 Finish part of basement to game room, used wood stove $900.00 SHEET 114 Y146&, � doc/- -.max—•—�eP--�� - 511512015 SlipGen - Portal Hone Town of Yarmouth Template [Building Dept] ■ Slipsheet Identifier [sg25659] Document Category Building Permits Map -Block Number 127.17 Street Number 0008 Street Name MERCHANT AVE Department Building Parcel ID 16039 Backfile Batch Scan No Document? Additional Naming Info Index Operator Operator, Yarmscan Date - Time 2015-05-15 - 11:23 httpJAaserfichel2JSlipGerV 1/1