HomeMy WebLinkAboutBuilding PermitsNUMBER THE COMMONWEALTH OF MASSACHUSMS FEE
Irr
of .
hpAr fIf,/,y Build g Inspector
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 hau�beyn issued by the Building Inspector." ".
to .� _ f Address
Inspection Dale./ / �
4v TYmbfnt lasp n0.... Inspection Date
....M�... Fire Depart a /' Inspection Date
Water Department IaspeNoe Date
Highway Department Inspection Date
Building Inspect o ....._ Inspection Date F�
sp
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 WITH TOWN REQUIREMENTS.
�rZ5t r„
........... _.................. Buildinf I ector
FORM 1231 Hosea a WARREN. INC.
VON
PERMIT NO FBTOWN OFYARMOUTH Building Department BUILDING
(508) 398-2231 ext.261
._..____PERMIT
ISSUE DATE :_ _7/9/2004_ • ; PROPOSEDUSE
APPucANT .'Luc iedPaai inc�redy - - _ - _ JOB WEATHER CARD
.. -• ---
PERMITTO ; Atteratkxa
AT (LOCATION) IM003KELP LN ZONING DISTRICTK2fl Bldg. Type: Resdentlel
SUBDIVISION MAP LOT BLOCK 1025,18 BUILDING IS TO BE CONST TYPE 5-B USE GROUP®
LOT SIZE
rebind and extend extsting root overhang over the flack deck 4 teetto meet the end of the new
REMARKS permitted deck
AREA (SO FT) EST COST ($ jS2.0D0.00 PERMIT FEE ($)
OWNER IPAUL F MCGRADY BUILDING DEPT BY
ADDRESS 1132 Hdlis Avenue
Braintree I MA 102184
CONTRACTOR
LICENSE 0
r
INSPECTION RECORD FIELD COPY
Date Note Progress - Corrections and Remarks Inspector
rJ
M
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, MA 02664-4492
Tel: (508) 398-2231 x261 • Fax: (508) 398-0836�-
011a Use Only
Permn No Date
Permit Fee 3 A5
Deposit Redd. $ ��j� DaiP
Net Due
Planning Board Infomneon
PIMTM
me ment Date
�a Recording Date
%an No.
Other
Assessors Deparlmeid Infomutiorc
New
1A Prop" Dimensions:
Lot ku (sf) FmnWe (ft) Lot Coverage
- This Section for Ohbe Use Only
Building Pe um r.
Date Issued:
-
Sig natu -
Official -- ate.. :
Certificate of Occupancy
is -.. _ is not ' required
Section 1 - She Information
I Use Group: R-4 Type: SB
1.1 Property Address
3 KeIg L,fle-
12 Zoning Information:
2a
Zoning District Proposed Use
1.3 Budding: Setbacks (ft) .
Front Yard
Side Yards
Rear Yard
Require d
Provided
Required
Provided
Required
Provided
I water Suiopiy (LOLL c.+a S 341
Public Private
1.5 Flood Zone Infamaeonx - .- - C rrmuda::. ._
Zone:BFE: '
Section 2 - Property OwnershiprAuthorized Agent
2.1 Owner of Paco
13a
Name'/ i �)Ma&QAddress8 '1 } tC, " 6 �k-r 8 p
signs re V Telephone
2.2 Authorized Agent:
Nye (pond) Ma7hq Address
Signature Telephone Fax
Section 3 - Construction Services
3.1 Ucensed Construction supervisor:
Mproable ❑
UN
1 6 004
Number
Address u tJZD m5�17
E!jflan Data
Signature Telephone
32 Registered Home Improvement Contractor.
CompanyHarne
Not Applicable ❑
Address
signature Telephone
License Number
Expiration Date
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure
to provide this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached Yes .......... No ..........
New Construction I No. of Bedrooms No. of Bathroans
Existing Bldg. it Repairs) QY I Alterations it I Addition ❑
Accessory Bldg. ❑ Type Demolition
Brief Description of Proposed Work:
GV
�o
MMF
• I
item
Estimated Cost (Dollars) to be
completed by permit appft"
1. Building
2. EiecYdcal
3. Plumbing / Gas.
4. MedraNcaI (HVAC)
5. Fire Protection
Ou a . • o
B.Total =0 +2+3+4+5)
7. Total Square Ft. (nee haaes i 02wo
Other Specify:
ovf-4 e,
end •1� Tht tjeAA-3
i
SCAFin•
Check Below
❑ Conservation Commission Filing .
(u applicable)
❑ Old tongs Highway & Historical
Commission approval
(d aWlcable)
_ , as owner of the subject property
hereby authorize to act on
my behalf, In all matters relative to work authorized by this building permit application.
sWah" of Owner
Date
, 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.
L, &: (% A` 6 mdy
Print name
&L �y1.11t
SI ture d owner/Agent Date
9.15-99 2d2
For Office Use Only
Permit No.
Date TOWN OF YARMOUTH
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
MGL c. 142A n quires that the `reomstrudion, alteration, renovation, tepair. mmWnintico, conversion,
improvement, removal, demolition or construction of hm addition to hmy pre Xisting owner-oowpied
building containing at least one but not mare thaw fav dwelling unit or structurn which are adjacent to
such residence or buildbW be done by registered coWactats, with certain exceptions, along with other
requsemems.
a�tie5 It ootc-liaA6�
Type of Work Dec% S�' t> •l Est. Cost o c . 6 0
1-420kf�rr ku5.1.0, r2�iCfS�i
Address of V / p a SJ o f%�iv -m >. sip
Owner Nan :lief A e ro l/1
Date of Pe ,plication: 6.Lde S
I hereby ..fy that:
Registration is not required for the following reason(s):
Work excluded by law
Job under S1,000
$udding 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 Registration No.
C•T;4
Notwithstanding the above notice, I hereby apply for a permit as the owner of the above
"
•. • �, 0,
The Commonwealth of MassachuseM
Department of Industrial Accidents
07COAUSAst/trS&M
600 Washington Street
Boston, Mass. 02111
Workers' Compensation Insurance AMdavit
Applicant information: MatePliflPf TedNEVi
a I jt f-
location• 3 / —
. Ya�..ofi1►. MA Sak'76%-J3/3
��..� Sb phone N
[�(am a homeowner performing all work myself. 7&/ ,8 YJ?
o lam a sole proprietor =d ha%c no one working in any capacity
1 am an employer pro%iding workers* compensation for my employees working on this job.
cum LJns• name•
address'
cwty• phone IF.
insurance co noliey N
I am a sole proprietor. general contractor. or homeowner (circle one) and have Erred the contractors listed below who have
the folloss ing %corkers' compensation polices:
c2mDAnv name• --
address*
city, phone N.
Failure to secure coverage as required sailer Section 2SA of MGL 132 no lead to the impoisdos of eeimiaN penalties ors not up to si.5w w asaror
oat years' Imprisonment as well as civil penalties is the form of a STOP WORK ORDER sad a flat otSttiOAp a day spiv me. I snide stud that ■
copy of this statement may be forwarded to the Oroce of InvnBptioas of the DIA for coverall verification,
t do hereby certify under the
Print name
penalties of perjury that the information prodded above is true and Corr OM
C
official use oniv do not write in this area to be completed by city or town offload
city or tows• YAM-K!U-Tfl
p check if immediate response is required
permitAkease N mBaildioa Department
plJeensiag Board
261 ❑Seleclmn'1Omre
❑111eslth Department
(SOS) 398-2231 t
contact person phone N; — ex - mother
oWr.yA
z
PLEASE PRINT:
DATE: 4 hq(c I
JOB LOCATION:
"HOMEOWNER"
TOWN OF YARMOUTH
BUILDING DEPARTMENT
1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 260
HOMEOWNER LICENSE EXEMPTION
(
'jj�- il' Epn STRE ADDRESS SECTION OF TOWN
u7.�l IrarodW 3 kw, t/. ,2tiv Sti�JI.l^�(.r/haJ�
NAME HOME PHONE rl 81-
PRESENT MAILING ADDRESS 13 01 I7b L - t s--h—pe- n ttt-
17-a93 -VaC�.2
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 su isor. (State Building Code Section 108.3.5.1)
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 structure 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 resoonsuble for_
all such work performed under the building permit (Section 108.3.5.1)
The undersigned 'homeowner' assumes responsibility for compliance with the State Building Code and other
applicable codes, dry -laws, rules and regulations.
The undersigned 'homeowner' certifies that he / she understands the Town of Yarmouth Building Department
minimum inspection procedures and requirements and that he / she will comply with said procedures and
requirements.
HOMEO WNER"S SIGNATURE
APPROVAL OF BUILDING OFFICIAL
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent, which meets the requirements of MGL Ch.142.
Yes ❑ No 0
If you have checked ym please indicate the type coverage by checking the appropriate box.
A liability insurance policy ❑ Other type of indemnity ❑ 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 of Owner or Owner's Agent Owner 0 Agent 0
Information and Instructions
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their
employees. As quoted from the -law', an employee is defined as every person in the service of another under any
contract of hire, express or implied. oral or written.
An e»rpinrer is defined as an individual, partnership, association. corporation or other legal entity, or any two or more of
tite 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
dw ellinc 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.
NIGL chapter I : = section 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, 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 haw e
been presented to the contracting authority.
Applicants
Please fill 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 fill out in the event the Office of Investigations has to contact you regarding the appl'tcam. Please
be sure to fill in the permittlicense number which will be used as a reference number. The aff davits 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
Mice d ImWilide is
600 Washington Street
Boston, Ma. 02111
fax #: (617) 727-7749
phone #: (617) 7274900 ext. 406, 409 or 375
TOWN OF YARMOUTH
1146ROLTTE28 SOLTTHYARMOUTIII MASSACHUSEM026644451
Telephone (508) 398.2231, ExL 261 — Fax (508) 398-2365
BUILDING DEPARTMENT
DEMOLITION DEBRIS DISPOSAL AFFIDAVIT
BUILDING
ELECTRICAL
GAS
PLUMBING
SIGNS
Pursuant to M.G.L. Chapter 40, Section 54 and 780 CMP, Chapter 1, Section 111.5,
I hereby certify that the debris resulting from the proposed work/demolition to be
conducted at 3 g A takf & —a yam°-j%
'Work Address
is to be disposed of at the following location �' G ✓mu � -2)L-3paS 0-Q
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, Section 150A.
P t E 'o
. ...,�
Permit No.
ditkd6
Date
TOWN OF YARMOUTH
Building DepartmenTTown
(OFFICE USE NLY
OOJ
Hall
Recorded By. Ic
YammtN MA 02884
permit F69: $0.00
(508) 398.2231 wQ.261
Deposit Rec: $25.00
Payment Type: Check ChkNo.: 1785
B
BUILDING PERMIT
Net Owed: ($25.00)
APPLICATION RECEIPT
Application Date: 6/15/2004
Issue Date:
Temp Permit No.:
T-05-001
Expiration Date
Applicant Name:
Lucille & Paul McGrady
Comments:
Location:
00003 KELP LN
rebuild and extend existing roof overhang over
the back deck 41eetto meet the end of the new
Owner's Name:
PAUL F MCGRADY
permitted deck
Owner's Addres
132 Hollis Avenue
Braintree MA 02184
Owners Telephone: (781) 848-8858
This is NOT a building permit. Application subject to plan review. Contact Building Department for permit status. Official
Building Permit will be Issued upon plan review completion, approval, and complete payment of Net Owed on Permit Fee.
Date Printed: 7/1/2004
�-
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132 Hollis Avenue
Braintree, MA 02184
June 8, 2004
BY FACSIA M E — 508-399-0836
W. Kean Bates, Building Inspector
Town of Yarmouth
1146 Route 28
South Yarmouth, MA 02664- 492
V, odica(.eaC i s CL-
IJCA,A
PL(Lli)'! ate GC�O �f7,
Re: 3Kelp Law —Building Permit Cat, 010/0Kc,`47v L/�vuxnpf—
Dear Mr. Bates: L
This is in reference to the building permit issued on June 4, 2004, to reconstruct and
expand our existing deck at 3 Kelp Lane in South Yarmouth.
Before beginning our construction, we reviewed the final plans as approved by you, with
the structural engineer. He has brought to our attention, and has recommended that the
existing roof overhang that is currently over the end portion of the deck should also be
extended four feet to meet the end of the new portion of the deck in order to make it look
right and Pr'oport►onal. Otherwise, he advised that there would be a column or stanchion
remaining in the middle of the deck, which would look strange and be in the way.
The structural engineer has drawn up an additional page showing the proposed .
reconstruction plan for the ovediM& which is enclosed. Also enclosed are photographs
of the existing deck showing the portion that is now covered by the existing overhang for
your reference.
We should appreciate receiving your further approval of the proposed modification to the
existing overhang. If you do approve this modificatiioq please advise us of the additional
cost for finther fees that would be involved regarding the estimated cost of the deck. We
estimate that this modification might cost us an additional S 1,500.00 to $2,000.00.
Please contact Paul weekdays at 617-293-4242 or please leave a message at our home
telephone number in Braintree at 781-848-8859, so that we can contact you when it is
convenient for you.
Thank you for your consideration.
Very truly yours,
�e,� �Ga � aul F. Lucille McCrady
Homeowners
Enclosures: Photographs and proposed construction plan for overhang
Original with enclosures by Mail
BUILDING
TOW OF YASMOOTH PERMIT
Ff p COPY
•�1 vsy -. aSOD
13-ai-big sl��%i
may 17, 2001 PERMIT NO.$-01-819
APPLICANT Paul & Lucille McCrady ADDRESS lag Hollis AVP _1trninfre— HA 09184 `.
(NO.) (STREET) (CONTR'S LICENSE)
re aira NUMBER OF
PERMIT TO D 1_1 STORY DW ELUNG UNITS
(TYPE OF IMPROVEMENT) NO. (PROPOSED USE)
AT (LOCATION)
v I BETWEEN
O CCROSS STREETI
P
L SUBDIVISION 25 11 A LOT
AND
(CROSS STREET)
U
0 BUILDING IS TO BE FT. WIDE BY FT. LONG BY FT. IN HEIGHT AND SHALL CONFORM IN CONSTRUCTION
O
Z TO TYPE 5B USE GROUP $ 4 BASEMENT WALLS OR FOUNDATION '
F
M((TYPE)
O
REMARKS: re:rODfF 801II9r Over OOe layer
AREA OR
VOLUME ESTIMATED COST
(CUBICISOUARE FEET)
OWNER Paul 6 Lucille McCrady
ADDRESS 132 Hollis Ave. Braintree. MA 02184
BUILDING I
BY_
25 0
z�. INSPECTION RECORD.
DATE NOTE PROGRESS - CORRECTIONS AND REMARKS INSPECTOR
•. l
WAY-II-01 01t4lob Fron-TOWN ADIIINISTPATORS OFFICE
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&XpRESS ]BUILDING PERMIT APPLICATION
TOWN OF YARMOUrH
Yarmollm Bn mwg vepa "Ml
1146 Roue 23
South Yarmouth, MA 02664
(SOS) 398.2231 Ext 261
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a TOWN OF YARMOUTH Building Department
+ (508) 398-2231 ext.261
BUILDING \
PERMIT NO :Fg1'3 __ __-_-- PERMIT
..scull ISSUE DATE 614l2004 PROPOSED USE ;
�• ........._
APPLICANT Lix:llie a Peal McGrady - - . _ - - _ - - _U JOB WEATHER CARD
PERMIT TO Attera6s
AT (LOCATION) jwoo3KELp LN ZONING DISTRI R-25 Bag. Type: Resaential
SUBDIVISION MAP LOT BLOCK 1025.18 BUILDING IS TO BE: CONST TYPE 5-B USE GROUP R-4
LOT SIZE
REMARKS replace and expand existing deck -12 x 32 as per plans submMed W1 &N.
AREA (SO FT) EST COST ($153.000.00 PERMIT FEE (E)
OWNER IPAUL F MCGRADY I BUILDING DEPT BY
ADDRESS 132 Hollis Avenue
Braintree I MA 102184
CONTRACTOR
LICENSE O
INSPECTION RECORD FIELD COPY
Date Note Progress - Corrections and Remarks )nspector
7-
E
F�ir1 nRtr= A. -rwn =ARAti V (1Ni V .RIM (•limn. PERMIT
G APPUCATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE
p y Town of Yarmouth Building Department
Y ... ,.... 1146 Route 28 - Yarmouth, MA 02664-4492
Tel: (508) 398-2231 x261 - Fax: (508) 398-0836
I Y D N
AP 1 s 2
Office Use On
Permit Date Y�
Fe l/
Permit Fee $96 /
Deposit Rec'd.00 Daf1t
Net Due $ p
Planning Board Information
Plan Type
End
EnPlanorsement Date
Recording Date
PNo.
Other
Assessors Department Informal : y
map La
New
1.4 Property Dimensions:
tot Area (s1) Frontage (ft) Lot Coverage
This Section for Office Use Only
Building Pe -t rnber.
Date Issued:
Signature:— —Q
Date
Certificate of Occupancy
. La - - la rat - required.
Section 1 - Site Information
I Use Group: R-4 Type: 5-B -
1.1 property Addresss
3 Kt/p L6 I:& -
12 Zoning Information:
925
Zoning District Proposed Use
S6:rM A
1.0 Building Setbacks (ft)
Front Yard
Side Yards
Rear Yard
Required
Provided
Required
Provided
Required
Provided
30'
/S' 120
'
1A water Supply (I LO.L c. 40. s S4)
Public Private
1.5 Flood Zone Information: - - Comments:
Zone: BFE:
Section 2 - Property Ownership/Authorized A ent
2.1 Owner ol Rseord:p
-
Mailing Address B(Lft �F1T�rn� O
YYnw` f �L
smg re Telephone
2.2 Authorized Agents
Name (print) - Mailing Address
Signature Telephone Fax
Section 3 - Construction Services
3.1 Liesnsod Construction Supervisors
Not Applicable ❑
License Number
Address
Expiration Date
Signature Telephone
3.2 Registered Home Improvement Contractor.
Company Name
Not Applicable ❑
License Number
Address
Signature Telephone
Expiration Date
O IV
1of2
OVER
Section 4 - Workers'Compensation Insurance Affidavit (M.G.L o:152 —S2-5-C—(-6-)J t r, .
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure J
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 No. of Bathrooms
Existing Bldg. ❑ Repair(s) Alterations ❑ Addition ❑
Accessory Bldg. El Type Demolition Other Specify:
Brief Description of Proposed Work: _ AB, i &. q wq cx7'q
t _
Section 6. Estimated Construction Costs
Item
Estimated Cost (Dollars) to be
completed by permit applicant
1. Building
2. Electrical
3. Plumbing / Gas
4. Mechanical (HVAC)
S. Fire Protection
W1 3 0li0 an
6.Total =(1+2+3+4+5)
7. Total Square Ft. (new houses a addtlors)
- Owner Authorization -To be Completed When
tent or ContractorApolies for Buildinq Permit
Check Below • -
❑ Conservation -Commission Fling
(lt applicable) '
❑ Old 16ngs Highway & Historical
Commission approval
(if applicable)
as owner of the subject property
hereby authorize to act on
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner
Section 7b
Q
Date
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.
Print name
cc - °fyirl� r 4
signs ure Owne Agent Date
9-15-99 2 of 2
For Office Use Only
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 pro-Odstmg owner -occupied
building containing at least one but not more than fir dwelling units or structures which are adjacent to
such residence or building' be done by registered contradors, with certain exceptions, along with other
requirements. `,,/
Type of Work: , Est. Cost -3i Vd d d 0
Address of Work
Owner Name:
ODU S, j
Date of Permit Application:
--ter
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
—jelOwner 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 trader 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.
Date 'I Oner Name
The Commonwealth of Massachusetts
Department of Industrial Accidents
exce 0/ere5912008S
600 Washington Street
Boston, Mass. 01111
Workers' Compensation Insurance Affidavit
Applicant information: PfeaserHolkhih
u
Tbr-76°-
QJ I am a homeowner performing all work myself. 7 ��
0 1 am a sole proprietor a-d ha%e no one workine in any capacity
O lam an employer pro%iding workers* compensation for my employees working on this job.
insurance co. polity 0
0 1 am a sole proprietor. general contractor, or homeowner (circle one) and have hired the contractors listed below who have
the follow in; worker' compensation polices:
company name -
address*
city phone N•
inmranr� rn. noticy 0
Failure to secure coverage as required wader Section 25A of MGL 152 an lead to the Imposition of erimbul penalties of a Doe up to 51,500.00 aswor
one years' Imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a ate of SI00.00 a day against me. 1 oodentaad that ■
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage veri0catloo.
[do hereby certify under the pains and penalties f perl'ury that the information provided above Is true apd correcg
Signature c / r//��" e M / ate T�J1�16 /oil o too
(J
Print name J—.l c 1 / LD A-1 /' � 6 nL� Phone 0 [ u / 9 O a �O
official use only do not write in this area to be completed by city or town omcial
city or town: YARMOOTII _
O check if immediate response is required
contact person:
permit/license 0 nBuilding Department
(3Ucensiog Board
261 OSelectmes's Office
(508) 398-2231 ext. OHalth Department
phoee a: _ _ nOther
'n. 3.95 r1At
Information and Instructions
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their
enrplo%ees. As quoted from the "law', an employee is defined as every person in the service of another under am
contract of hire. express or implied. oral or written.
An ernphgyer is defined as an indis idual. 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
ow ner of a dwelling house having not more than three apartments and who resides therein. or the occupant of the
dw elling house of another w ho 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 emplo%er.
%IGL chapter I5= section :5 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.
Additionall%. neither the commonw ealth 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 affidaviL 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 fill out in the event the Office of Investigations has to contact you regarding the applicant. Please
be sure to fill in the permittlicense number which will be used as a reference number. The affdavits 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
Mice If IMstlt>tdln$
600 Washington Street
Boston, Ma. 02111
fax #: (617) 727-7749
phone N: (617) 7274900 ext. 406, 409 or 375
TOWN OF YARMOUTH
BUILDING DEPARTMENT
1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 260
PLEASE PRINT:
DATE: z/b G A y
JOB LOCATION.Cv
PRESENT MAILING ADDRESS
HOMEOWNER 110ENSE EXEMPT70N
So
)N OF
WORK PHONE
�3/3
STATE ZIP CODE
The current exemption for 'Homeowner' was extended to include owner— occupied dwelling; 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 Section 108.3.5.1)
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 structure 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 rMnsible for
all such work performed under the building penni . (Section 108.3.5.1)
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 requirements and that he / she will comply with said procedures and
requirements.
HOMEOWNERS SIGNATUREt
APPROVAL OF BUILDING OFFICIAL
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent, which meets the requirements of MGL Ch.142.
Yes ❑ No ❑
If you have checked yes, 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.
Signature of Owner or Owner's Agent
Check one:
Owner ❑ Agent ❑
n3wmeownnoccump
TOWN OF YARMOUTH
1146ROUTE28 SOUTHYARMOUTH MASSACHUSEM02664-4451
Telephone (508) 398-2231, Ext 261 — Fax (508) 398.2365
BUILDING DEPARTMENT
DEMOLITION DEBRIS DISPOSAL AFFIDAVIT
BUILDING
ELEGMCAL
GAS
PLUMBING
SIGNS
Pursuant to M.G.L. Chapter 40, Section 54 and 780 CMR, Chapter 1, Section 111.5,
I hereby certify that the debris resulting from the proposed work/demolition to be
conducted at
Work
is to be disposed of at the following location: Y4/'NM" 611n �1iit Sx
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, Section 150A.
Signature of Applicant
Permit No.
-r 6
to
V4VTOWN OF YARMOUTH
Building Department
Town Hall
Yamwuth. MA 02664
(508) 398-2231 e&261
BBUILDING PERMIT
APPLICATION RECEIPT
Temp Permit No.: T-04-518
Applicant Name: Lucille & Paul McGrady
Location: 00003 KELP LN
Owners Name: PAUL F MCGRADY
Owner's Addres 132 Hollis Avenue
Braintree MA 02184
Owner's Telephone: (781) 848-8858
(OFFICE USE ONLY
Recorded By. Ic
Permit Fee: $0.00
Deposit Rec: $25.00
Payment Type: Check ChkNo.: 1743
Net Owed: ($25.00)
Application Date: 4/16/2004
Issue Date:
Expiration Date
Comments:
replace and expand existing deck -12 x 32
ZONING APPROVED_
This is NOT a building permit. Application subject to plan review. Contact Building Department for permit status. Official
Building Permit will be issued upon plan review completion, approval, and complete payment of Net Owed on Permit Fee.
Date Printed: 4/22/2004
o4'Y-A ff``
Building Site Location:
Address:
x'Ie
.60 TOWN OF YARMOUTH
BUILDING DEPARTMENT
BUILDING PERMIT APPLICATION DEPARTMENTAL SIGN OFF
A TRANSMITTAL SHEET
The Building Department will be responsible for assisting the applicant
applicable departments.
No: Lot No: If
y
plans and or application to the following
WATER DEPARTM 4T:
Determines Compliance of Water Availability and or existing location.
ENGINEERING DEPARTMENT:
Determroes Compliance for Parking and Drainage.
CONSERVATION COMMISSION:
Determines Compliance to Wetlands Ads; Le•, If Lot(s) Border any Type of
Wetlands, Streams, Ponds, Rivers, Oceans, Bogs, Bays, Marshland, Etc
HEALTH DEPARTMENT.
Determines Compliance to State and Town Regulations; i.e., Requirements
For Septage Disposal and other Public Health Activities.
FIRE DEPARTMENT:
Determines Compliance to State and Town Requke ents for Personal
Safety, Property Protection; i.e, Smoke Detectors, Sprinkler Systems, Eta
REVIEWED BY:
1. WATER DEPARTMENT: DATE: N/A
2. ENGINEERING
HEALTH DEPARTMENT. DATE
3. WIRING INSPECTOR: DATE NIA
6. PLUMBING INSPECTOR DATE N/A
7. FIRE DEPARTMENT DATE: N/A:
COMMENTS:
RECEIPT OF COPY: SIGNATURE OF APPLICANT: DATE:
WMe W"-Bc1M[DRL• Pmkowy•W&WDWL • YCI1—00PJ•H=MDCPL • PMk CWy•E00-ffma D%L = d®d•Fks Degx'• �
• 04•YgR'ri i
O /
Building Site Location:
Proposed Improvement: 17,
TOWN OF YARMOUTH /o � ?5'
BUILDING DEPARTMENT
BUILDING PERMIT APPLICATION DEPARTMENTAL SIGN OFF
TRANSMITTAL SHEET
Ij
1;
No: --2-15-Lot No:1�
Address: /3JG% t7Ti O Te1No : %�'/ XkS$ate Filed y�G
The Building Department will be responsible for assisting the applicant by Z/1 a g Your plans and or application to the following
applicable departments.
WATER DEPARTMENT: Determines Compliance of Water Availability and or existing location.
ENGINEERING DEPARTMENT: Determines Compliance for Parking and Drainage.
CONSERVATION COMMISSION: Determines Compliance to Wetlands Acts; ix, If Lots) Border any Type of
Wetlands, Streams, Ponds, Rivas, 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 DEPARTMENT: Determirm Compliance to Stlke and Town Requirements for Personal
SafeyA Property Protection; i.e, Smoke Detectors, Spnnkla Systems, Etc,
PE$VIEWED BY:
✓1. iWATERDEPAR'IMENT.
2. ENGINEERING DEPARTMENT. DATE: N/A:
V13. CONSERVATION: DATE: N/A
HEALTH DEPARTMENT: DATE: N/A:
7. WMNG INSPECTOR DATE: N/A
6. PLUMBING INSPECTOR: DATE: N/A
7. FIRE DEPARTMENT% DATE: N/A:
COMMENTS:
RECEIPT OF COPY: SIGNATURE OF APPLICANT- • DATE:
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TOWN OF YARMOUTH
BUILDING DEPARTMENT
BUILDING PERMIT APPLICATION DEPARTMENTAL SIGN OFF
A TRANSMITTAL SHEET
Illmrr5mlffm• ✓. • MWV WAR.ice ' r • r • /
Address:
applicable departments.
RESIDENTIAL AND/OR COMMERCIAL BUILDING
WATER DEPARTMENT.
Determines Compliance of Water Availability and or existing location.
ENG WEERING DEPARTMENT:
Determines Compliance for Parking and Drainage.
CONSERVATION COMMISSION:
Determines Compliance to Wetlands Acts; Le, If Lot(s) Border any Type of
Wetlands, Strearns, 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 DEPARTMENT:
Determines Compliance to Sthte and Town Requirements for Personal
Safety, Property Protection; i.e., Smoke Detectors, Sprinkler Systems, Etc.
REVIEWED BY:
RE
✓1. WATER DEPARTMENT. DATE: N/A
2. ENGINEERING DEPARTMENT: DATE: N/A
�� D
V 3. NSERVATTON: DATE: N/A:
HEALTH DEPARTMENT. DATE 5 /YL��N/A APR
2 6 2004
3. WIRING INSPECTOR. DA77i N/A
6. PLUMBING INSPECTOR
7. FIRE DEPARTMENT: DATE N/A
V .M t1
RECEIPT OF COPY: SIGNATURE OF
DATE:
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LOT NO.: TG ADDRESS:ZA�41 Gl/)P
OWNERS NAME: 1 Ile,/ �•
j SEWAGE PERMIT NO.:
NEW: REPAIR•
DATE ISSUED: DATE INSTALLED:
CBS NAME :
i INSTALLATION OF:
WATER TABLE: FLNAL' INSPECTION •W: Sjq�7
DRAWING OF INSTALLATION ON REVERSE SIDE:
GIB2015 StlpGen- Portal Home
Town of Yarmouth
METemplate [Building Dept]
Slipsheet Identifier [sg267181
Document Category Building Permits
Map -Block Number 025.18
Street Number
0003
Street Name
KELP LN
Department
Building
Parcel ID
805
Backfile Batch Scan
No
Document?
Additional Naming Info
Index Operator
Operator, Yarmscan
Date - Time
2015-06-08 - 13:56
hltp/AaserAche121SlipGerV Vi