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Home My WebLink AboutBuilding Permits (2)OF'AR,� �r 0 MATTA � ti �n [l A CECE=.IVE NOV 23 2015 BUILDING D I T A Office Use Only SHEDS LESS THAN 1:0 SO. FT. SHALL BF PLACED A MINIMUM OF 30 FEET iAme'm= 3�— FROM THE FRONT LOT LINE AND A PermitexpiresISO days from MINIMUM OF 6 FEET FROM SIDES AND issue date hFArq LOT LINES, S SHED PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: O� l7 91 LtQ / Gt �• dt�' 07.�� ASSESSOR'S INFORMATION: Map: 0 Parcel: if OWNER: PRESENT ADDRESS CONTRACTOR: pit ff TEL # Email Address: NAME MAIUNG ADDRESS TEL # Email Address: Residential Commercial ,t Est. Cost of Construction I';- Home Improvement Contractor Lie. # W / d Construction Supervisor Lic. # /" 14 Workman's Compensation Insurance: (check one) I am the homeowner I am the sole proprietor I have Worker's Compensation Insurance Insurance Company Name: Worker's Comp. Policy# SHED INFORMATION / ft t n i &IAI& ,?xcocrf�t.� �Lc n rj//Ic1f� New Size Lff-:�_x W J0 G x H_2 Per Town of Yarmouth Zonine By -Law See 203.5 E.- Side and rear setbacks for accessory buildings less than 150 square feet and single story, shall be 6 feet in all districts, but in no case built closer than 12 feet to any other building. Replace existing* _ Size L, x W x H *The debris will be disposed of at: Location of Facility I 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 denial or revocation of my license and for prosecution under M.G.L. Ch. 268, Section 1. Applicant's Signature: Owner Signature (or Date: Approved By, Date: Building Official (or designee) Peer Y xTIIfie, YCGLcz Afa�d Zoning District: Historical District: Yes No Flood Plain Zone: Yes No Water Resource Protection District: Within 100 ft. of Wetlands: "** Yes No Yes No ***Note: Conservation review required if within 100 ft. of Wetlands 9/13 The Coninionwealth of Massachusetts Department oflndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 wlvw.mass.gov/dia lVotkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Name (Business/Organization/Individual): Address: City/State/Zip: Are you an employer? Cheek the appropriate box: Phone #: I.❑ I am a employer with employees (full and/or part-time).* 2.❑ I am a sole proprietor or partnership 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 4-M I am a homeowner and will be hiring contractors to conduct all work on my property. I will Y'kensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5.❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.: 6.❑ 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 required.] Type of project (required): 7. ❑ New construction 8. ❑ Remodeling 9. ❑ Demolition 10 ❑ Building addition 11.❑ Electrical repairs or additions 12. ❑ Plumbing repairs or additions 13. ❑ Roof repairs 14. ❑ Other •"V u.a.,,.._"., VUA MI 111wL mso uu ovc me section neloW snowing tnerrworkers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors 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. 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 MGL c. 152, §25A is a criminal violation punishable by a fine up to $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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. one # Official use only. Do not write in this area, to be completed by city or town officiaG City or Town: Permit/License # 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 employers 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 enTloyer 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 -contractors) 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 Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia Abutter's Name Lot # 1010 If this is a comer lot, write in name of street. PLOT PLAN MpP 10 1 FOR LOT # �Gtru_I l� Y Additions w� hed= or cozy building Sewmage dUWuj (ceasponl) Neu >� (••,b��y ' ..• •........••.it. real) SIDE YARD REAR YARD ..0' YG, ....ft, a ..: SET FACE (NAME OF STREET) 0 W9► � e�I SIDE YARD ri, a Abutter's Name Lot # If this Is a corner lot, write In name of street. puve'r Town of Yarmouth Conservation Commission Building Permit Sign -off Application TO BE FILLED OUT BY APPLICANT: Q -- // f/ Building Site Location: A06 ce& e /COGI� A1ap # Lot(s), # /(0 Property Owner: Applicant: �p me Applicant Address: �5?/yLLp Telephone:_;P�-T-1�9 Date Filed !/lo /S roject Descr!p tion: t s /� I7 v //t //. r/ 0. TO BE FILLED OUT BY CONSERVATION ADMINISTRATOR: Do You Have A Valid Permit Front The Conservation Commission For The Proposed Project? �A. Comments front Conservatimmission: Approved Conditionally Approved Rejected All work related debris shall be taken offsite or disposed in a legal upland location At the end of each day, the area shall be clean and no debris shall be in the Resource Area Refer to: SE83- or DOA permit c u i Il \,,)auc sono -I-u bi_,S -ror <S� Consenvation Commission Sign -off Signature: It �Date: f � 1p• 1-5 11/2-rvZl5 SIIpGen - Portal Home Document Category Map -Block Number Street Number Street Name Department Parcel ID Backfile Batch Scan Document? Additional Naming Info Index Operator Date - Time Town of Yarmouth Template [Building Dept] Slipsheet Identifier [sg37835] Building Permits 101.164 0200 BLUE ROCK RD Building 13654 No Operator, Yarmscan 2015-11-25 - 08:02 httpJAaserfichel2/S1ipGerd 1/1