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EXPRESS SHED PERMIT APPLICATIO• E C E I V E D
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28 AUG 27 2018
South Yarmouth, MA 02664 I�r,.��
(508) 398-2231 Ext. 1261 BUIL" ill •1 !."._J r
1 '/ ' By. f
CONSTRUCTION ADDRESS: 44 7 Go' kirk, {1•,()LA-4N ft) r--I--
.
ASSESSOR'S INFORMATION:
Map:
L 1 �Parcel:
7� / P 1} }[ r�y'
OWNER p NAM[tx l c , M Ti LJ�.l PRESENT � 1 @t `Q 0. I 1 ckrrno In'1k 1 a r 1 S TEL # �.` 11.1 _
CONTRACTOR: 10�1OV ^(r/�(Ui
NAME MAIL[NO ADDRESS ��,*� // ✓�•t,
tesideatial 0 Commercial EscCostofConstruction3J� ' to00
Home Improvement Contractor Lie.# Construction Supervisor Lie.k
Workc Compensation Insurance: (check one)
m the homeowner 0 I am the sole proprietor 0 I have Worker's Compensation Insurance
Insuraompany Name: Worker's Comp.Policy#
SHED INFORMATION
New _ Size L x W 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 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. sgareObv�
Replace existing* _ Size L x W x H
ale iti6 C'aNs7'�- c-760
*The debris will be disposed of at (o Vito ✓1.4'Y 1 S'
Location of Facility
I declare under penalties of perjury that the stat-men erein coat'• true and correct to the best of my knowledge and belief. I understand that any false answers)
will be just cause for denial or revo ' n of' ;04, 1►f on under M.G.L.Ch.203.Section 1.
�A Ecant's Signature: , 4 A / • I o
PP �r !• .l.v� � ( ,/ Date: �-1 � O
.S(wners Signature(or attachment) ., .Q.re I J&-, Date: W/ 2-1 ) e
�� G Q
Approved By: ,_/ A / Date: D— 7 " i O
` Building Official(or desi Muer EMAIL ADDRESS:
- `1�'a�I 9 II Ok t�� _ Zoning District
.
4,11 H'is'toneal District y/ Yes fl No Flood Plain Zone: f: Yes C No
{{{...!!!"' Water Resource Protection District: Within 100 ft.of Wetlands:ens
•
Li Yes C No f1 Yes 13 No
• ***Note:Conservation review required if within 100 ft.of Wetlands
9/13
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// The Commonwealth of Massachusetts
n=
_,.,�_bit • Department oflndustrialAccidents
• : I
6 _::�- 1 Congress Street,Suite 100
$ =_ = Boston,MA 02114-2017
%%fa sp 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): 11 in K- 6 C\
)
Address: AY'Y)�p i �_ as V A b , _
City/State/Zip: Phone#: .
Art you an_employer?Cheek the appropriate box: Type of project(required):
LEI I 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.]
(�/i�I am a homeowner doingall workt 9. Demolition
—\ myself No workers'comp.insurance required]
4.0 l am a homeowner and will be hiring contractors to conduct all work on m property. I will 10 ❑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.❑Plumbing repairs or additions
5.01 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 an a corporation and its officers have exercised their right bf exemption per MGL c. 14.0 Other
152,31(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.
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:
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 c- and-ft.p'' an• 'e e ' • of perjury that the information provided above is true and correct.
•
4ienature: r . :i',���104f Date: g/�-7/it
Phone#: 309. 11R fr lc, 5017
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#:
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, PLOT PLAN
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FOR LOT Il
Indicate location of garage or accessory building
Additions with dashed lines
Sewerage disposal (cesspool) ED
Well is
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_. _ _ � I (lot ft. rear) I
Abuttor's 0 - In j\,_ — -' —
Name I 1_ ('0 ]) 1 ---7%-11
Lot A
I— -- .-I. ._. I <5-- Name
Lot i
:f this is a REAR YARD
orner lot, c this
nits in name I ft. corner
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kf street. I write
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