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EXPRESS SHED PERMIT APPLICATI
TOWN OF YARMOUTH R E C I= S f P C
Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664 A,6 20 2013
C /fir (508) 398-2231 Ext. 1261 BUILDING,oEpt ,ii rl—
CONSTRUCTION ADDRESS: PO Iy/ etse t,t L✓`owk
ASSESSOR'S INFORMATION:
Map: e'� Parcel: Q^� > Q
OWNER r .2.10. cCt."iZp t Octt'rl�{ ( / g'62 33-aza
NAME PRESENT ADDRESS TEL #
CONTRACTOR: 907b. .
/' NAME MAILING ADDRESS TEL.8
ye.y ❑Commercial Est.Cost of Construction S
Home Improvement Contractor Lie.$ Construction Supervisor Lic.R
Workma��. 's Compensation Insurance: (check one)
}�f 1 am the homeowner 0 I am the sole proprietor 0 I have Worker's Compensation insurance
Insurance Company Name: Worker's Comp.Policy#
/ SITED INFORMATION
t
New Size L /1 x N a x H // Corner Lot: Yes_ No .
Per Town of Yarmouth Zoning By-Law Sec 203.5 E:
Side and rear setbacks for accessory buildings less them 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 TY" x ll
*The debris will be disposed of at
Location 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 answer(s)
will be just cause for denial or revocation of my license and forprosecution under M.G.L Ch.263.Section I.
Applicant's Signature: Date:
I. e A
Owners Signature(or attadunent)• t_ Date: }� 7
Approved By: ✓—cc Date V - cko - if
Building Official(or designee) EMAIL ADDRESS:
....,.__..T
Zoning District
Historical District '1 Yes 0 No Flood Plain Zone: n Yes C No
Water Resource Protection District: Within 100 ft.of Wetlands:***
17 Yes C No Il Yes No
***Note:Conservation review required if within 100 ft.of Wetlands
9/13
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• The Commonwealth of Massachusetts
A_e i--- — /
e_ Department oflndustrialAccidents
ce .
=__i:Mt'1I= f 1 Congress Street,Suite 100
e,, 'Ffc Boston, 2114 02114-2017
'itc,�,4 www.mass.gov/dia
Yorkers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual) J2 'tC G4_R.b
ti "(
Address: (OR- l"eec✓�p .._.r I c(P . I
City/State/Zip:0- yo-v•luaT4_ Phone#: 97g--�33`'Z2-7S
Are you an_employer?Check he appropriate box: Type of project(required):
1.0 I am a employer with employees(full and/or part-time).* ' 7. ❑New 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.]
9. ❑Demolition
.....,./3. I am a homeowner doing all work myself. [No workers'comp.insurance required.)t
10 ❑Budding addition
.❑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,§1(4),and we have no employees.[No workers'comp.insurance required.]
"Any applicant that checks box WI 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 She 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 certii and, a pains and penalties of perjury that the information provided above is tru• and correct.
Signature: I 1 " Date: • e# /!
Phone#:
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#:
y. .
•
++f • PLOT PLAN
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FOR LOT N FOCe� N
Indicate location of garage or accessory building
Additions with dashed lines
Sewerage disposal (cesspool) et
Well 0
I I
I (Int ft. rear) I
Abutter's CP —
— —' -
Name I Abettor
Lot It I 301 Name
t' Lot P
f this is a REAR YARD /J
tamer lot, ft. / If this
vrita in name corner :
of street. ' I
write ii
�, name of
a I aother
v� r Pi street.
.
: SIDE YARD
HOUSE SIDE YARD •
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SET BACK .
.
ft.
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a
(lot ft. frontage)
/
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(NAME OF STREET)
\ Information
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Information and Instructions
hfaewCb�ra General Laws chapter 152 requires all=cloy*"to(avid'wane'estop/Nation he cher empb)eaa. ,
Pursuant to ILL statute,is vapiga Is 4.6.4 as• .every person In cher=vice of another uadrt any=sad albite,
express or implied,oral or Hither."
As arp(gw L dead main individual,pactoerahtp,aaodLtbrr carparedaa at other legal achy,or any two at mon
at the bnping snppd be'joint alerprbe,and locking the legal orprvmdns ofa dame=employ=or the
receiver or uses alas hdMdaa.perssabig,meochitos or otter legal ea Iiy employing engloyess. Howes the
owner ofadwelling honer brig not mass talkie Aprtia =ad who reeks tram*or the aampnt of
dwelling bars ofawber wbs employs peace to ds maLsaasca,coosincdos at mak work era net dwelling lass
or ma Ina pack a Melding spprssetat thereto shell not because of sock enphymeat be damed s be an=grayer
MOs.duple 15'2,125C(6)abs sasses that"say stats w loaf Ileendeg every shall withheld Me Swum et
road eta Cane or permit be errata a bmtaer tie s eesstrr.4 kir the In the aerssawupf be ay
appti--'whe la net preload sersphhk masa if malls with the lereraas caws,restated."
Addidonagyds tbe cominconsitk nor
ime way,Ma espies 152,1125C(7)sae Contra be 5 p pubes wadi acceptable evidence a ha political with the mel. c.
requitals of this chapter Mn ben prewnrd as ILC eoatractng authority."
Appsaas
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nib supply nub maaer(a)ammeUb albeer(a)and phos number(s)along with Ther crthleale(a)at
SWUM Limited Liability Compass(Jig or Lased Liability Prmaehipa(IR)with a agisyess atter Gra the
mambos rp as=an not r aked to any aka ooagn edon lonraaa. Its LLC or LIP doss brae
employees,a podgy is required. Be daisd dot clots aids=ay be submitted to to Thiantnenst of Industrbl
Aoelda'floe cosfirmrloa otimresce coverage Abe be vers l sign and date w afildavN. The emdadt should
bsnamesetbecity errtows die the appsatbsd rthepermitwsewbbegtegemied.setdrDeplanes of
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fadskLl Amides Said gas have ay qua=repots eke law ss try=am required s oaks a=dons'
compeer dem posy,plow sal Wer Deprtnast at the wake lied below. Saks=campedss shaeld eller their
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Pins be as at the Omdsria Is conpba sad printed kpbty. 13s Depr>mut has pavidad i spas lbs bates
oldie amdavit lot yea is ff1 oat In the event the Omce of healptiaas has contact you regarding the Replica
Masa be as to till ha eke pre at.w mast which will be mad as a Mance nmrobe. In=dila.an applicant
than tart alba*muffle malice=Applicata'in ay plvea yew.ted Sy submit ate Stink'-'t Skating caws
past'nlrrdoa(It4aceory)sad omit"fob Sae saw"the apptksst should weer"all beans le (City or
taws}"AcopyafIkeamdavitthatisk'sSlatatlyseamedamer}dbythecityartownmaybepoddedsethe
setae spread=a valid dada Is asfi5 he has pun=alaerer. Anew'Blank oat behied out sack
year.Theo
(La a dog Scenes or gm=te bun leaves Cas)said pram 6:707 regrind is complete Ibis amdavit
11r oma of levadptiar would lbs te dunk lee Is admen Ix yew couperadoe and said you have any swed =
pleas drmtbegat sgive uraat
Iia Deprnant's sae=telephoto and Iter numbers
The Commonwealth of Massachusetts
Depertmeat of Indtatial Accidents
Oat.dram:tlpdms
600 Washington Street
Boston,MA 02111
Tel.A 617427-1900 ext 406 or 1477-MASSAFB
Revised 11-12-114
Fax 16!1.727-7749
www.maa.gov/des
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