HomeMy WebLinkAboutBLD-19-001822 ! PSG' 11 IAN :`n GO .L I Office Use Only
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EXPRESS SHED PERMIT APPLICATI a ; E C E I V E D
TOWN OF YARMOUTH
Yarmouth Building Department SEP 2 6 2018
1146 Route 28
South Yarmouth, MA 02664 aY t ' 7 s -
(508)398-2231 Ext. 1261
CONSTRUCTION ADDRESS: 5 I c-v weri'vk io I\O r2- 2.\ So jt-k,
/ W-ntoJ 1
ASSESSOR'S INFORMATION:
r Map: Parcel:
OWNER -trr.Nco t • (Lon,tr•o - 390- 6SOp0
NAME PRESENT ADDRESS TEL #
CONTRACTOR:
NAME MAILING ADDRESS TEL.if
fTResidential 0 Commercial Est.Cost of Construction$ 0,S CO
Home Improvement Contractor Lie.Of Construction Supervisor Lic.R
Workman)Compensation Insurance: (check one)
am the homeowner 0 I am the sole proprietor 0 I have Worker's Compensation Insurance
Insurance Company Name: Worker's Comp.Policy"!
STIED INFORMATION
New _ Size LIS x fY /0 s H 10 Corner Lot: Yes_ No t
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.
Replace existing* _ Size L1`51 Nam
in x II /0_
+
'The debris will be disposed of at 71`Q..t 10J � 6v AN,,e
// 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. I understand that any false answerls)
will be just cause for 912b1 , 9
denial vocal n of icense and for prosecution under M.G.L.CI1.263.Section I.
Applicant's Signature: rL��1 Date:
Owners Signature(or attachment) Date:
Approved Ey; Date: -pt0 s /8-
Building Official(or designee) EMAIL ADDRESS:
..._...-
Zoning District: �~._..
Historical District -I Yes 11 No Flood Plain Zone: !1 Yes , No
Water Resource Protection District: Within 100 ft.of Wetlands:°i
0 Yes C No I1 Yes 0 No
• "'Note:Conservation review required if within 100 R.of Wetlands
9/13
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__ The Commonwealth of Massachusetts
t =-`I—�'/ Department oflndustrialAccidents
e "211k-,
i =_loll= 1 Congress Street,Suite 100
if =4F!r' Boston,MA 02114-2017
.,;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): -c-y Vsvy.r cc N , 0-0 m-. -,O •
Address: 5 1 C Vtip'M .w e_ \z
City/State/Zip:SoJ \ y'frQano.. C . Phone#: Co n- - 310 - G 8 Og .
Are you anemployer?Check the appropriate box: Type of project(required):
1.0 l em a employer with employees(full and/or part-time).* ' 7. 0 New construction
2.0 1 am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling
epy capacity.[No workers'comp.insurance required.]
3. f em a homeowner doingall work myself t 9. 0 Demolition
y [No workers'comp. insurance required.]
10 Q Building addition
4.❑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.Q Plumbing repairs or additions
5.0 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.❑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 boxtr 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.
tCont actors 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 under the pains and penalties of perjury that the information provided above is true and correct
Signature: Date: 7 /20 l/ a I/
Phone ii: (D Pr ^ 190- ( 60P
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.CitylTown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
•
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1) - 4. .
44 .. PLOT PLAN
, p. ,
FOR LOT N
Indicate location of garage or accessory building
Additions with dashed lines
Sewerage disposal (cesspool) ED
Well to
I I
— _ _ I (lot ft. rear) I
Abuttor's 0 — — —
Name I G Abuttor'
Name
Lot N
I
I I 1 Lot M
f this is a REAR YARD
xrner lot, ft. 3D If this
mite in name corner :
if street. writeI
f
name of
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is ,o street.
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SIDE YARD
HOUSESIDE YARD
.
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• SET BACK
•
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(lot ft. frontage)
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