HomeMy WebLinkAboutBLD-19-762 • ,PYA}, ''•r .,z1 1=`51i1.c•U :.`4:' "Yr f1 .,hl '!.I !Office Use Only
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�'•+:�us�: Permit expires 130 days from
'WY issue date
EXPRESS SHED PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
• 1146 Route 28
South Yarmouth, MA 02664
(508)' 398-2231 Ext. 1261'
CONSTRUCTION ADDRESS: /�f/ $ i 't ' Ayr
r
•
ASSESSOR'S INFORMATION:
Map:e';(177/#1
Parcel:rc (,3
OWNER: "c& 71.4,. G/v77PRESENT
f,leal d/ /�.3) �i'3DGBS��
CONTRACTOR: ME SSSS
NAME MAILING ADDRESS TEL.#
❑Residential ❑Commercial Est.Cost of Construction$ �O
Home Improvement Contractor Lie.# Construction Supervisor Lie.#
Workman's Compensation Insurance: (check one)
0 I am the homeowner 0 lam the sole proprietor O I have Worker's Compensation Insurance
Insurance Company Name: Worker's Comp.Policy#
/ SIIED INFORMATION
New ✓ Size L x 6V /0 x H /.3 Corner Lot: Yes No
Per Town of Yarmouth Zoning By-Law Sec 203.5 E:
Side and rear setbacks for accessory buildings less than 150 square feet and single stay, 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 hV x N
*The debris will be disposed of at:
Location of Facility
I
declare under penalties of perjury that t • ements herein con•• r ed are true and correct to the best of my knowledge and belief. I understand that any false answerls)
will be just cause for denial or mac of 0. ' e a A• secvUon under M.G.L.Ch.263,Section I.
Applicant's Signature: _ �- Date: 8 �Q,6 /Qv
Owners Signature(or attachment) Or — — Date: O lJ �//
Approved By:_ Date:
Building Official(or designee) EMAIL ADDRESS:
Zoning District: ,.µ�........w_ • _,__._..........._.
Historical District: -1 Yes t'I No Flood Plain Zone: 'l Yes Ti No
Water Resource Protection District: Within 100 ft.of Wetlands:•"
Yes i_ No U Yes 0 No
• "'Note:Conservation review required if within 100 ft.of Wetlands
9/13
__ The Commonwealth of Massachusetts
1-Willir—Sr at-. Department oflndustrialAccidents
M ial_ • 1 Congress Street, Suite 100
€.1;:_g_=4, Boston, MA 02114-2017
�4 www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address: /4// 5I7/lj/1/ ,d//C
City/State/Zip: , rite Phone#(- 6',12 9�3D-lp/S9 •
Are you an employer?Check the appropriate box: Type of project(required):
1.01 am a employer with employees(full and/or part-time).* ' 7. 0 New construction
' 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling
any capacity.[No workers'comp.insurance required.]
3. I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
9. 0 Demolition
4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will
10 0 Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
proprietors with no employees. 12.0 Plumbing repairs or additions
5 0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 Roof repairs
These sub-contractors have employees and have workers'comp.insurance.;
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.0 Other
152,§I(4),and we have no employees.[No workers'comp.insurance required.]
*Any applicant that checks box$I must also fill out the section below showing their workers'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.
:Contractors 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 MOL 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 certifyu •pains and penAfs of perjury that the information provided above is true and correct.
Signature: ear Date: i' 'i- to
Phone#:
Official use only. Do not write in this area,to be completed by city or town officio! .
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 1 Building Department 3.CitylTown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
,
• a. •
«4 PLOT PLAN
FOR LOT # 6)C
Indicate location of garage or accessory building
Additions with dashed lines
Sewerage disposal (cesspool) ED
Well 037
P zK'Z- ,v�'c,G 20
— — — I (lot ft. rear) I
Abuttar's 0 1.1 — - -
Name I Abutter'
0
Lot N I Name
I Lot N
f � a REAR YARD
orner lot. UD, ft. >f this
trite in name carnet
f street. Ibiti write i
I P, name of
aother
b o street.
4
I
SIDE YARD
• HOUSE SIDE YARD
d-11_1T� -1 _ : .
a- F � .
•
.
I .•
• I I
�� SET BACK •
.
��: � ...3 O...ft. .
I
I
I
0
(lot ft. frontage)
�/ cc/Corti/ AUi
(NAME OF STREET)
Information/ \ Supplied by IGU 1i7 /V L1
•
IARK NORTH POINT
•
Information and Instructions ,.
&'-3 as Garai Lawn chant 132 requires all et ployiw to provide working'compaosatioa Pox their employees. '
Pursuant Is this struts,as ewplejat Is defined a tasty paws is the service of another under rq contact of hire,
enplane a implied,out or writes"
As splays is dotted mesa mdtvidual.pactoembipr smirk*corpmatioa at other lepl arty,at say two or ala
of the beeping engaged la s Jotat ealuprimiad MSS.the bp!tepreemeadrw ale dexesad mar"a the
receiver a atatae of as badfia
dal.parahiLp.maoeiatiaa or other lip!Rola employing employees. Swam S
awns aftdeeilitt home having not ran the three aprtmaob and who resides therein.at the moped tithe
dwelling have of swabs who employe paean to de mrfelmame,wnatmetioa at mph wad as suck dnil g house
oras the pomades a butidfeg appurtenant thuds shag not because ofsock employ ant be deemed to be employer."
MIG.chapter 132,p3CY0 ales arse for"every state se kcal llnaigapsy akell withheld the imam sr
naewel ate Ikea°sou permit to epees a bears of a c arrset bu ldbrp is din esmmeawalth be say
applaud wM km ret pwdaed septa*adders of asopheam with the laenree ammo nater."
Addltlma!%MOL ampler 132,12387)sores"Weiths the xomoaweabk nor any of it political maYrWom shell
eats for ray contact tax the pets.of public wadi until acceptable aeon of manganese with the Mem
ngsiemrtof this chaps lave bas pneaued to thecarat*nsiriq.•
Applloesta ,
•
Pim fig or the workers'aapmaaloa addadt conpletaiy,by checking the bores is apply to yaw siaatioe and,it .
oeoasoy,supply sub etracta(e)sme(s),editor(*)and plow omba(s)ally with their cadfiesr(Q)of
ins ne. LimWd Liability Cookies(LLC)or heeled Liability Pataaahipe(LLP)with neo anptsyae odes thea the
members or pater;ate out required to any warkae'oo mmetiaa laureaa. It=LLC or LLP does have
employees.a polky le agaked. He akar the this efildark my be submitted to the Depaens of tadaaedal
Aaoidaar
at aafirmeios of lantana coverage. AM he ase to sip sad dale Ike amdavk. The aledsvit should
be aeeasd r the sky or lows flat the applied-a fie dr emit at lime is being nrprer&eat the Demmer of
• fadaairAMMO. Should you ban soy me tle esregardingthetawmilysae"rtadrabatismetre
compeneMs peaky,piwe call tb♦Depseaer a the acrobat U.S below. Sel$losed ammosi as should ester their
selfMases Beene swim as t e apempitess Has,
Clip w Tows Om-lok
Please be me the the affidavit Is complete and prated legibly. The Wprtmed hes provided i space a the balm
ottbe abr.at you to ffi out is the ewes the ORM of kwadgtioes yuan to rooted you regarding Ike applicant
Pleaes bean to AH Is the pard raw wan which wUl be aed es a rel7rerw numb* v addictor nee applicant
tis ma submit flask*pemtiYBemws applications Say give yes,need Sy submit sae afildevk lodkatini meat
Ids kind=(It y)ed under gobble Mikes"the epp&at should stir"all location Is (city or
tows).*A copy af fit atadnk the ken bee oMtlo ly stamped or=dad bythe city or town ay be provided r the
applkagrmad thatavaleslitvklasfilobrMoe panda orIleeaut Aram aka neat befilled out sack
yeas:When a home neat at cid=is°heehaw a Meow at month not retard to my*aka or oa®aeial roam
(Lt a dog Ham or permit to Mn kava ea)aid pars la NOT remised a ampler title salsa '
The Oaks at lawsdptiwr word like to that yes le adrume tar your aopaatlaa and should you haw say madam
please de not bran r give us a air,
fire Deprsad'w address.*Whom sod ba°umbar
The Commonwealth of Massachusetts
Depethment of Industrial Accidents
01U..if Gnndptleae
600 Washiagtoa Skeet
Boston,MA 02111
Tei.1617-727-4900 ext 406 or I.877-MAS&AFB
Raised 11.224141Fax M 617.727-7749
wvrw.mmt.8ur/dies