HomeMy WebLinkAboutBLD-19-1042 '4 1
/ -irn•: t f--7.-1:5 I I IAN 111:1-2 fl( F 1 ;;H-:..1 'Office Use Only
'5= 0 riv.•:','t THE :oofJrl_crli:'J ',r
E .i•,`1 'Per)���� -/s ib
6( c -itr..irMuz OF t r[CT i f;Q\1 F;11 -:i AND .Amount 35�
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�,^^* u'"to ?Permit expires 130 days from
issue date
EXPRESS SHED PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664
• Y4-((508)3348-2231 Ext. 1261Q �uCONSTRUCTION ADDRESS: /q/y /Im ei- , ay d •,^"1 44ill
ASSESSOR'S INFORMATION:
Map: Parcel:
OWNER EfA%/ $30rela / p R1nG /uJ Mi—e49.-- 3^ G4/ .-- I�
3
NAME 'h4.Cre//N-�'Y jvT ltD sI<s S/On4/
TRhitt
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coNAcro . %nc$°, T 8CC Cr h.Sri hit t ak, Me em _
NAME MAI LW nDi flit- TEC a I7to,G vaCy —ap6-z .
esidential 0 Commercial/ 0 Est.Cost of Construction S /t7f J 0 0 G�// s
Home Improvement Contractor Lie,4 /4(.0 9 3 V onstructian Supervisor Lic.if Cr S r / U O /[�
Workman's Compensation Insurance: (check one) ,
0 I am the homeowner 0 I am the sole proprietor have Worker's Compensation insurance
Art-
Insurance Company Na LU C tC.•! d j1 Com-pfay/Worker's Comp.Policy# /-7 - va Per/1
c • J1 SITED INFORMATION
/
New Size L (J a PV 70_s H 9 ff 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 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 PI T 7
*The debris will be disposed of at �,i .L c 14,1 / z t z eer
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. !understand that any false answerts)
will be just cause for denial or revocation of my license and r. servtion under M.O.L.Ch.263.Section I. /�
/�i fiC V /L/
Applicant's Signa . �ir2.� r / Date: 1U
/ 4 ie
t/ Owners Sign Lure(or attach ent) � '40 Date: OE/
'? / �`
Approved By: /�', � Date: v Z'/o
Building Official(or y ':•' EMAIL ADDRESS:
_
Zoning District: • _
Historical District: 1 Yes t'I No Flood Plain Zone: ^ Yes C No
:ZE
Water Resource Protection District: Within 100 ft.of Wetlands:*** �' ' �'" °'j
0 Yes C No 11 Yes I) No
***Note:Conservation review required if within 100 ft.of Wetlands ,1r" 2 1 2019
tC'/r/tP ,Teio1
. • The Commonwealth of Massachusetts
.0�e- �1t Department of Industrial Accidents
c =lull_ § 1 Congress Street,Suite 100
e_IFf_ Boston,MA 02114-2017
�z.� www mass.gov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electrictans/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): none8x.erit cc n
Address: 6OO & SI`7t )47.C/4)47.C/4 ,1i2 J t ciitc .260
City/State/Zip:p�, $ 74 Al Phone#: (4‘ —026 V-6267 •
Are you an employer?Check the appropriate box: Type of project(required):
1.0 1 em 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 g, ❑Remodeling
any capacity.[No workers'comp.insurance required.]
9. ❑Demolition
3.0 I a homeowner doing all work myself[No workers'comp.insurance required.]t
10 ❑Building addition
4. i am a homeowner and wilt 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.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.❑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 S'!�
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
"Any applicant that checks box ii I must also Ell 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.
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: //
�- U `i k fv it- j/7L,,J—nieLS
Policy#or Self-ins.Lie.#: ///G 03 a es--" Expiration Date: /../ ///.2o/?
Job Site Address: 11 Perenet 2cir1- " City/State/Zip: /0, fir& nv/U4r
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 per'ury that the information provided abov trueltnd correct
Signature: 44 LGI i Date: a'i
Phone#: ?k/ a'l q —G 76
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.CityfFown Clerk 4. Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
.ado . �"�_�- ,s,rifii
,/) `" t. .
PLOT PLAN
FOR LOT I(
Indicate location of garage or accessory building
Additions with dashed lines
Sewerage disposal (cesspool) ED
Well 0
I I
Iact ft. rear) I
Abuttor's 6 `C r '0 — "
Abutbor'
Name I
Lot It ( x "d Name
Lot M
:f this is a ( REAR YARD
turner lot, 1 ft. If this
vrite in name corner •
'f street. I
write L
( -, name of
a. other
to C street.
its4
3''i
SIDE YARD SIDE YARD .
HOUSE ••
:
•
•
I •
•
:
•
SET BACK •
. .
.
•
ft.
.
1 --
(lot ft. frontage)
/ 19 P/rlt 2C)
4 (NAME OF STREET)
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