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�''++,'"i/ ' ',Permit expires ISO days from
--'r,:;"""• i issue date
EXPRESS SHED PERMIT APPLICATI I tv E C E I V E D
TOWN OF YARMOUTH
Yarmouth Building Department 2"] 2018
1146 Route 28 AUG
South Yarmouth, MA 02664 '
' (508)3198-2231 Ext. 1261 eye t• DEPART �.
CONSTRUCTION ADDRESS: G 0 12;\Y.,�S \rev ylt �A`f{,
ASSESSOR'S INFORMATION:
'\\ •
Map: •1 \0 Parcel: Li
OWNER W\\\\TY� 99.-z--al , -1^13$-133 I 3-7,1
NAME PRESENT ADDRESS TEL. #
CONTRACTOR
� //�� NAME MAILING ADDRESS TEL# ,q7
d'Residential 0 Commercial Est Cost of Construction S /�i7 • v
Home Improvement Contractor Lie.# 1 Construction Supervisor Lie.
Workmaifyeompensation Insurance: (check one)
I am the homeowner 0 I am the sole proprietor 0 I have Worker's Compensation Insurance
Insurance Company Name: Worker's Comp.Policy#
SHED INFORMATION 5C-41. d siontie
New _ Size L x W x H Corner Lot: Yes No X Cd,gAC/Df/CS * dei
Per Town of Yarmouth Zoning By-Law Sec 203.5 E: C d/!. k?Cfydl9
4
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 If
*The debris will be disposed of at
Location of Facility
I declare wider penalties of perjury that the statements herein contained ars true and correct to the best of my knowledge and belief. I understand that any false answMa)
will be just cause for denial or revocation of my license and forprosecu nder MAL.Ch.263.Section 1.
Applicant's r vatum: illtDate: p
Owner ignature(ora .clime i���. Date: $^a'1- '6
Approve. c . of
�`!�= Date: r-'7 Or
Building 0i .-1-!' ) EMAIL ADDRESS:
Zoning District its,-�I...lb
�_— • -_._.-.-a..___..__
Historical District aeYes Il No Flood Plain Zone: ia4es 0 No
Water Resource Protection District: Within 100 ft.of Wetlands:***
0 Yes C No fl Yes ller No
• ***Note:Conservation review required if within 100 ft.of Wetlands
9113
•v The Commonwealth of Massachusetts
n -_ .
g_,_ ,�_r Department oflndustrialAccidents
p =%ill_ y1 Congress Street,Suite 100
_` T_j•Boston,MA 02114-2017
*...,;,,s 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): IN \�\ tar..` i)E T,?.tK,` •
Address: tta lh\stv-.), es\\,.p t0.1S1
City/State/Zip: y4.1\.n-,e...0„ '\_,Q � Phone#: st %— ry 5 i n 4 .
Are you an employer?Cheek the appropriate box: Type of project(required):
1.01 am a employer with employees(full and/or part-time).* 7. Eew construction
• 2.01 am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling
any capanity.[No workers'comp.insurance required.] t-��
3. am a homeowner doingall work9. L7 i�em01iuon
myself[No workers'comp.insurance required.]t
4.0 I am a homeowner and will be hiring contractors to conduct all work on mY property. I will 10 Budding addition
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 subcontractors 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
152,31(4),and we have no employees.[No workers'comp.insurance required.]
'Any applicant that checks box 4 I must also fill out the section below showing their worker'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 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 certify nder ie airs and p aloes of perjury that the information provided above is true and correct
Signature: V Date: N' 27'-) ?
Phone#: In - -11) ( S ),
Official use only. Do not write in this area, to be completed by city or town offtciaL .
•
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#:
a4t— - . -- .arair'
,1) _i,v.
-r3 PLOT PLAN
FOR LOT N
Indicate location of garage or accessory building
Additions with dashed lines
Sewerage disposal (cesspool) 49
Well 0
I I
I (lot ZOVAr ft. rear) I
- - - - rnflat\
Abuttor's 0 '— — ,
Name Abuteor'
I
Lot Name
$
I Lot t
X this is a REAR YARD
:owner lot, If this
'rite in name ft.
corner
'f street. I write i
name of
O. other •
v ,a street.
3+, 4
SIDE YARD
HOUSE
SIDE YARD
s d--- -it-
fin eatT-? �D I n
• I LET BACK
E
•
Ass I ft.
I -.
1
{ q 0
�?0
(lot ! t ft. frontage)
/ " a� C 1
\
(NAME OF STREET)
` Information
Supplied by
•
LARK NORTH POINT '\\\ny` k Z2U
h
• `'• 4
Information and Instructions ,.
PClatitinaittsGenteel Laws chepon 152 requires ail employirs to provide wacna a'campenadoa Em drat uwlayne..
Pursuant b tab statute,as arpiayew is defined as tinny pawn is the sinks of another under sq Conrad of hint,
express or implied„oral or written"
As aryleys is defined seas ioditidn4,partnership,sea dartos,empondos at other lap!any,or sny two or mon
oaths ianpitg anpfid is gain mi lou the legal nprassadr a ale deenwd=plops at the
main or Mutes of as L.dlridaal,prtrarship.auodados or other bpi eadt%employbfi employes.. gown the
owner otadwelling boars anis not mon lass them epartmroat and Moe midis there*as the acconst of
dwelling hone of another who employs patter m de ostmwon,aaarttrdon at mak out as sock deans haw
a as the paunch at building apportion'than shad not because ofsock employmoat hs darned m be as employer."
Ada Sow ill,page)also sow the"envy dale as Mut Ustaahag agiary shall withheld Me an ee
renal deIkea sepen*tie sprats aSimms semsalter!Width"isthe aemessralt req
applaud who ks.N pndussd sseeptabls adesss of ampdew will the brans ern.rented."
Additimedy,MW.chops 152.f25Q7)ams lift the coomonsahn nor ray alits poEdcal subdivisions shell
caste into ay canna the the preens ofpubds work until acceptable evidente atcomptimos with the L...nce
requiran old*oapls hen bees maned to the connoting author*"
Appleton •
Masa MI at the worbws'eompmutiaa amdnit completely.by checking the boas tart apply to yam siteedos roti,if
snsssss7.apply oda)ssms(s%sdlmo(..)sad phone numbs(s)sag with their cavitas-(+)at
Susan Limited Liahil tog Carpdes(LLC)or Lilted thief rutaraNps(UP)with as esopisy.ns Gibs thea the
membssSperms.ass not regaidmany worl,se'carps--"--banns If as LW atLLP tee Mrs
mployar,a pulley is mared. Be ebbed that this alien may be submitted m the Denson at fa take
MOMS Em confimatios of insane caraaga Aim he las l sip sad date the Madan. The affidavit shroud
beMad tethe airyatIon that the applicants ltrthe pang arSae la befog rmgssated.net the Deprmdof
•
Inborn Aeons Shand yaaham sq Wsssrsoe regmdeg the law or Wpm as rsgdred te obeli•workmo'
aomPsarlor pcdm peen call the Deprtmes s demobs:than below. Seifdosrwd wmpaiaa should are their
sdW incense leers resets as as swards lima
Clywawa aikido
Iles bit sum the the alder'Is compete sad minted legibly. The Department the portdd i space s the batons
of rho aldevis the yam m Ell out in the eras the Olsce of tsaadgriss bee m costed yore regarding the sgpUeat
Plan he an m fid los the permtaNesesr oast thick will be sed as a mince mass bt addition as sip l a4
der met submit pennants application is say$va yeas mrd aelysuheit one affidavit Mikado{cisme
pansy bid(doss y)ad aim inns Mks"the applicant rirsd min°al bcedoas is (city as
town)."A copy afthe Olden tbehem bees alibi*stomped armond bythe cityar tows any bapatridd m the
applaud sproof thee evalid affidavit basEnbrban none arIk as Anew gladioli ant bsfilled outsch
year.When a bona amiss re citizen b abtaiog s ikons or pease on meted to my buns at ea®aa W masse
(La a dog theses arpanic aboa hares et)said pan bNOT remind mmama this saint.
The Wee of tavadptios would lib to'Mak yes b sines Er yon co sea tiros sod should you here sny dp estions
place de not harass m give ore a cat
(he Deprars'l adding.Stephan sail As m-a--
The Commonwealth of Mssaacbusrtt
Depsnmeot of industial Accidents
oma.ifIa.eetlpdsn
600 Washington sheet
Boston MA 02111
rd.M 617-727-1900 ext 406 or 1-$774(ASSAFE
Raised 11-22-116Fax 1 617-717-7749
www.m>aa.gor/din