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`- 4"+•w'"E/ �, Permit expires ISO days from
.- ' .. issue date
liy i E ,HYMEN it
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EXPRESS SHED PERMIT APPLICATION�`
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
- South Yarmouth, MA 02664
/��7y (508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS: LJ! �/ AY 1e-R f T✓C!Sr .Lya Ron° as 673
ASSESSOR'S INFORMATION: ii 5- /YJPr,n) J/ naisnot...)TIN,
PktAY ffD_ , ` /ffiMap: Parcel:
OWNER: C7gc_I- ES ,gw &n re avec- lJyaoint trit Sa8= g9Lf--0 a ':•
P
NAME r a9PRESENT ADDRESS / TEL. 4
69N-TR t Tern: Md¢ret /1aa aSr 11! >Qei 0414 d9 o/SD7 .
NAME MAILING ADDRES TE .If
sa say
❑Residential 0 Commercial Est.Cost of Construction S SIJ
Home Improvement Contractor Lic.N Construction Supervisor Lic.N
Workman's Compensation Insuranc`e': (check orae) '
0 I am the homeowner y I am the sole proprietor 0 I have Worker's Compensation Insurance
insurance Company Name: ' ` Worker's Comp.Policyf
/ SITED INFORMATION
New y Size L x W x H (p / 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 story, shall be 6 feet in all districts. but
in no case built closer than 12 feet to any other building. //�
N- 071 D..), / �-74t
Replace existing* At Size Lied x IY• a x II
"The debris will be disposed of at: /1/4. ze QG-$
Loeatlon of Facility
I declare wider 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 answens)
will be just cause for denial or• • • • . h rra se and for prosecution under M.G.L.Ch.269,Section 1.
Applicant's . gnature: /C.41111r - y Date: / &0 Ga
Owners mignature(or an et nen /� r_ Date: �J�
Approved 13y: •- i I Date: WS
Building 011k . •si•tcc) EMAIL ADDRESS.
-
--- Zoning District:
- �,� �• ,_-`�^
—
I listorical District: -1 Yes 11 No Flood Plain Zone: it Yes r, No
Water Resource Protection District: Within 100 ft.of Wetlands:t"
I] Yes C No 17 Yes 1 No
• ***Note:Conservation review required if within 100 IL of Wetlands
9/13
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The Commonwealth of Massachusetts
=—n •
Ems Department oflndustrialAccidents
__"ldl=
I Congress Street, Suite 100
_`�:-_ 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 L Please Print Legibly
Name (Business/Organization/Individual): /e'//fLe. GAAiEy
Address: v2.9 SnX Ic12 # Vt IA) ,/✓-}2rn n i 1.
0.1
city/state/zip:: synth-kw—SI Orad 13 Phone #: re- L/9 - Q57-A .
Are you an employer?Check the appropriate box: Type of roject(required):
LEI am a employer with employees(full and/or part-time).* ' 7. Iew construction
• 2.0 1 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. ❑ Demolition
�-�{
10 0 Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
proprietors with no employees.
12.❑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.❑Other
152,§I(4),and we have no employees,[No workers'comp.insurance required.]
'Any applicant that checks box#1 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. Lie.#: 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 tinder e pans and penalties of perjury that theinformedprovided above is trite and correct.
Signature: ' I C �a�-dram ced nk T C� )4. te:
Phone#: e D t4- Li! 9 Lf- CT 4 F • �crok- 74 9-Acor
Official use only. Do not write in this area,to be completed by city or town official •
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#:
id.
N. •
• / ., PLOT PLAN
, r• ,
FOR LOT M
Indicate location of garage or accessory building
Additions with dashed lines
Sewerage disposal (cesspool)
Well 27
I I
— _ I (lot ft. rear)
Abutbar's 7/ fl' — — —'
Name
Lot M I Abutter'Name
1- I Lot t
:f this is a REAR YARD
orner lot, ft. If this
mite in name I corner •
of street. write L
I
a name of
a other
o v street.
L7• 3'i
• SIDE YARD
• HORSE SIDE YARD
a-- - -- _ 0 p----- Dil) .
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I
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SET BACK •
42 ft.
I ..
I
0
(lot ft. frontage)
i/ 027 )3t-ycrcR Ave
(NAME OF STREET)
Information
/ \ Supplied by
PARK NORTH POINT
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Information and Instructions
hider Boater Central Laws thi s 132 icquka all amploylr to provide radon'compenntios tar their employes '
Pursuant a this statute,as esspleyeet is defined as"awry paras is the rake of mother under any caaaact of hire,
tapas a bapled,oral or nine"
As sea ten is dated seas individual,pstmsabip,as.oafias,co:paratlas or other lepd nary,or say two a more
of the lbnpiy sappd is s joist ealsprbe,ad iaehdag the kid npaemdws of s deceased employer,a the •
receiver atones Dias IadMdus,.patoasldp,arocLtlas a other lipl entieyi employto*satployesa Howes the
ower as dwullkg his brag not mors than three span aadwho resides tart*as rho=opal oar
dwetlhag has otamtaer who employe pea to ds mei" "u,wstacdon or sea work as sada dwelling house
at as rho pounds madding see aeaae abase shall not bosoms ours employment be deemed to he a Employee
MOL shaper 132.123C(6)ales star IS"every data ea Mal Unadagapq shall withhold Me henries er
rand de Sass et permit he operate s bass et to andrest addles Is rho aaveswalta Aar s4
applleasl who Ma net pndand seseptal u aides of salsas s with the asses caw rapine
Additlo sily,MW.choPse 132,123"x7)sons"NoLaec the camonnal t nor soyais political subdivides shag
eater a try contact Its the praosos ofpubgs wort until acceptable evidence ofcampitaos with the Surat
require ate of this duper have ben pr aed to tae ctassodog a thorit.°
Applauds
Phone til out the wades'compaatbs glide*coo pletsk by checking the bases that apply to your siastlos sod,if
necessery,soppy s+baora(s)msa 'X ddaw(es)sad pia naovbeds)slag with their nrtifiwa(()of
imsama Laded Lability Compass(LLC)a Laded Liability IramaaMps(LLP)with a employees other thaw she
members orpita ere not required to any an'compandae In----. Was LLC a List Is it,.
Es plo,.a a pisy M atpaked. He eddied dna tale affidavit may be submitted to tate Depauad of fadsrrW
Atridsae fir casffrmados of(owed coveag. Aka be nee to aka sad dale de dada It The'Ma should
be ratais the city a ewe dot the appeasers dr the psskatliar is bay rwpured,set rho Deanna of
• Mara Manta Shoed yes hon a y r casks reg rdlng the law a dyes as mad is oasis s moat
compeer'_palsy,plies call dr Depma at Soma land below. So1Hoemdd cam a s should pass their
self.an fie rinses Taber a the apereeside lies
Clq se Tows Omdale
•
Please be site that rho aerie is cora as and prated legibly. The Department has provided:spar at tae boa
*Abe amara br yes to fig out is rho event the arta of tavedpdesa hes m coated you reprdeg the applicant
Prase be are to nil ha the panarlic me amber which win be mad as s adrenal nambec Is oddities,a applicant
Thee at admit aridple pealiete applicadoos lay give per,need onlysteat ore acSdavk Indicating ducat
policy tsbrandas(If aeeeesay)ad tabs lob Me Mass"the sada aid wile"ail tondos Is (city or
tows)."A copy of the sidsvit diet hs bees o>sa W lap stomped a naked by the city or mets may be aided to the
applicant srattail svalid affith.kaostgebrthese pas aIkea Anew Rads*art befitleaoat each
yea.Wives a ha now or Ea is obrided s lame or permit at added today business a eaaxaacld reads
(Las dog lame or mak as baa kava fie.)said pores is NOT nova to tabs the affidavit
The Oaks of favesdpdms would IS to thank you Is anon the yaw caner dol should you has say pada.
plater do sat hesitate to gin m s cat
The Centoo s's address telephone sera As numbers
The Commonwealth of Massachusetts
Department of Industrial Accidents
Wks of Invndptlesur
600 Washington Sheet •
Boston,MA 02111
Tel.0 617-7274900 ext 406 or 1-877-MASSAIS
Revised 11-12-114Fax 0 617-727-7749
www,mamgpv/iia
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