HomeMy WebLinkAboutBLD-19-000968 J F". -'):= ! Fry 11 IAN _ 10 F :�'ra• ! ' 'Office Use Only
'� r
OF'Y9eq . .: ;1 :Gtdo;t';NI . si- ez_a1
•.- I-. ;: .1:1L '•r.i. PermifJ
.1.v1 r
QH "41f.JJ.11 7q;;r )."- E.:F CT Pfau,.,t :il;- '":ilhi:i l :Amount �.J�-�
''""°"%' .Permd expires 130 days from
'issue date
• W)4q-11RECEoE� Ej= i
EXPRESS SHED PERMIT APPLICAT
TOWN OF YARMOUTH Or-
UG 20 2018 ' '
Yarmouth Building Department _. ._4 i
BUILDING DEPAIlTMEr ;f 1
1146 Route 28 nr
' South Yarmouth, MA 02664
n /�,,n (508)3998--/2231 Ext. 1261 / 1/
t/CONSTRUCTION ADDRESS: 90 C4 f 7 //? a43 e Ro adI l J�OI,C`� Z Vargo/clic.
ASSESSOR'S INFORMATION: /
Map: Parcel:
1. -'6ANNER l s a nxo A?f c hake°v 90 Caetza in C&( id, 1 Yarn-meg
NAME PRESENT ADDRESS TELL. #
CONTRACTOR: 5-03-367- 208
/ NAME MAILING ADDRESS TEL.#
1/ Residential 0 Commercial Est Cost of Construction$ / J CCO v"
Rome Improvement Contractor Lie.# Construction Supervisor Lie.#
Workman's Compensation Insurance: (check one)
0 I 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
V Size L 5 s 6V iti x H /2 Corner Lot: Yes_ No
Per Town of Yarmouth Zoning Bp-Law Sec 203.5 E:
Side and rear setbacks for accessory buildings less than 150 square feet and single story, shall he 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 If
*The debris will be disposed of at
Location of Facility
l declare under penalties of perjury that the statements herein contained an true and correct to the best of my knowledge and belief. I understand that any false answerls)
will be just cause for denial or revocation of my licen-+ and for prosecution under M.G.L Ch.263.Section I.
Applicant's Signature: i Date:
Owners Signature(or attachment) /I )` 1 Date: of/iv/log
Approved By: _4*i _ Dale: d-2O-VV
Bti . .r•ffic', . des: t,t e)1 EMAIL ADORES ,_.—._.............,..-.....,-. _.......�.�
Zoning District:
Historical District: -I Yes fI No Flood Plain Zone: '1 Yes 0 No
•
Water Resource Protection District: Within 100 ft.of Wetlands:'**
I2 Yes C NO 11 Yes ID No
• "'Note:Conservation review required if within 100 R.of Wetlands
9/13
• The Commonwealth of Massachusetts
• Department ofIndustrial Accidents
1 Congress Street,Suite 100
Boston, M4 02114-2017
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): 75a!7ko /'ire /vir1roV /,/
Address: 3d �Qr n Ckie Aw 1 c0 (,LTL Yarmarek
City/State/Zip: D.26ay Phone#: 01-367-728
Are you anemployer?Check the appropriate box: Type of project(required):
1.0 ern 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. 0 Remodeling
any capacity.[No workers'comp.insurance required.]
3.5j I am a homeowner doing all work myself[No workers'comp.insurance required]r
9. ❑Demolition
10 0 Building addition
4.0 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.
12.0 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,§1(4),and we have no employees.[No workers'comp.insurance required.]
*Airy 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 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 untie tet./�s and penalties of perjury that the information provided above is true and correct.
Signature: x/141/ Date: 0//io,>ot 0 ieri
Phone#: '
Official use only. Jo 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#:
./ -' g• •
PLOT PLAN
.... '
FOR LOT # '
Indicate location of garage or accessory building17
Additions with dashed lines
Sewerage disposal (cesspool)
Well 0
I
I
I (lot ft. rear) I
Abutter's
I Cs fa
—
NameAbutter'
Lot # I Name
I Lot #
f this is a REAR YARD
1----1 ,`orner lot, ..____ThIf this
'trite in name •••••••,,••••ft.
corner .
if street. I
. write ii
, name of
ro0 a other
lstreet.
4
: SIDE YARD •
HOUSE SIDE YARD •
: •
a-_- _-may 0 a co .
•
I •
••
•
SET BACK
•
•
Q.
Lt. •
.. I -
I
I
0
(let ft. frontage) /,�
�� 90 Cap?a;n aase toceo�, �. Ya rmoce IGS
(NAME OF STREET)
Information
Supplied by
!ARK NORTH POINT
Information and Instructions
bilecbutas Cacal Lain chapter 152 tequilas all sugbyia m provide wade'catannados ex dark employees. '
pursuit m this tbtatte,as sloa'e
Is doled s"...oma,pass Is the service of enatha est say catrad albite,
amen a bapl td.out at writs.*
As ugly. asocisti. comma at adds laid Sty,a at ta
say twon
tal,
at the tamping amid
4 "ter slant
ser cepass,sod befing the legal relrrereradsus of a dsemad employ a the
rens at oh
tree s iadvidsl,piiethip,associadss or ads Mal diel:employing es4lspsss. Bowe the
owner of a dwelling boots briars dot some them fire gene and who adds as toeits roues
dwelling boas of ands who=plop past m Si metsmeme,wesrucd s aapsb ork deomad m t dwelling smpbpr i
at a the ptmdit a building apptses0'0t
thaslsshill notbeenofsuchespyopmmt
?NZ ahaptrr 132,I23C(6)sass tales that°nay his eo lied litanies mesa tad withheld the I ms rd
nesse st kite sr paint is operates Sins se to este hwi41sgs Is dm aesseddi ter um
sppSed was W at preSsi sats endow et spleen with rte lest arms,rgsir irhal1
Additionally.MOL chaps 132,123C(7)wear hisser the cannot wealth oar any at las pulitcei subdlehiosr
es Is asy antrrat the is pumas+of Sas wain until acceptable evadaee of c:ampliaas with the hssxseas
segdraoals o[ddt':bans ban bees alarmed m tae ceatradsg woody"
Appeals •
Mese di as the eters'cengeaslos affidavit 000gYetly.by Sikhs as bans that apply to yes firers and,It
soa.oasmaamM)o.ms(s),sd tww(es)ad shoes s±ds)along with dist ccdtc.e(e)of mom dam
lase Lerim ted Lhbelyr Carpetss(LW)a Lhdmd Lfbiliy yci s>dips(UI)with a splays
e not smoked to cease morkas'oswp nssa
s bream It an Tic or LLP doss in
minis at aeon*t pea.
Is,.geed. Hs save that Ms affidavit mayens come Ales be see s Sole a is 0rpt sad date Ms 't 3 affidavit should
bAnkle ereneme Srasayoss r dot tbe sppgadosOaths pais aI' Mbeissa4serad.sotmsDemonsof
• Indaaai 'Aaidasa Med yes bre an V erdes rgerdleg the law as if you w rs4and w abets a merlon'
compound's pay,plass all the Dasteesd m tae tombs Ikrd beds. Selidetsd c eweshould ager the*
sales Weser asset at the ssssorbms lieu
at,sr Tars Melds •
Ns be mu thea the affidavit Is coag{.+and pie legibly. 'lbs Dupasat bas prodded s stew r the brass
of the
ss amdads las yarn nit oat is the Office
be aasd astir y sheso cants. ht rddidas.as aptagrading the�pilwes
Plisse be aur m - iso the army selfless ss i.rah sties peer.awed ay submit as aflldavi dtdfadng cr est
sudsthey 6 abmit srYtiM y). snake sled mils"ad batons Is (city at
tows) Acastsgfase�ny)adssder paceSlee g.,..,�' sir by telecity asowsmay bspunl lisvas
ams}"Asspo fdd'valid
vdnatbrasba Slit ix
oOen Asaw affidavit etbeAlin assack
applies
W ss pouf did r m or thin I abealsbeg a•tis br Iltbss ps Has or o not abed to any bane a t---- id mass
yea. Waw s hs t pawn a bra Mammo a pre Is NOTT..pI. d m copies de a airrk
(tea s dog liars a pesssit
TM Ails at tameadpdaS would Imo to than pas Is advance*n yaw mead=and should yam bow say guasdos.
pass ds mat SSW s gin ussca.
Um Copress'e skims,tstepbss ad tela aurae
The Commonwealth of Massachusetts
Oeps ttM t of Sushi Ardtkats
Oats of laratlptbas
600 Wrhlostoa Stud
Boston,MA 02111
Tel.1617427-4900 ext 406 or 1.877-MASSAFB
Fax 1617-127.1749
Remised 11.22416 www,ttlnsf.gpm/dice
•
e_