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HomeMy WebLinkAboutBLD-19-2677 ' •• Use Only 'l .' of �+ , rN-0001% 7 3 '` , kAmmmt ' c Permit expires 180 days from . issue date EXPRESS BUILDING PERMIT APPLIC S TOWN OF YARMOUTH RECEIVED Yarmouth Building Department 1146 Route 28 NOV. 02 2018 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 y' f OEP. ., ' • CONSTRUCTION ADDRESS: 2 2. C_) ASSESSOR'S INFORMATION: • Map: ' J Parcel: nit- OWNER: —[—&w• Q • 1'L e-V�d-t lit z�cv1.�s esy T 203 K 35 NAME I pp PRESENT ADDRESS - TEL. # CONTRACTOR: CL.u... 4 lel,._ 4 "1--010 S. Ye.,.ot. -1-f C't8 3eiYgg37 NAME MAILING ADDRESS TEL.# Iftesidential 0 Commercial . Est Cost of Constructions 3C.00tom- Home Improvement Contractor Lic.# 6,06'3 Construction Supervisor Lie.# 132•Ate 57 Workman's Compensation Insurance: (check one) I 0 I am the homeowner p`I am the sole proprietor 0 I have Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy# WORK TO BE PERFORMED Tent _ Duration (Fire Retardant Certificate attached?) . Wood Stove Siding: #of Squares Replacement windows:.# Replacement doors: # Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation Old Kings Highway/Historic Dist. ( )Replacing like forflike Pool fencing 'The debris will be disposed of at y&j i.-Irs.0 r" rc....c,.,►.o-i 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 answer(s) will be just cause for denial ocationof my li ,.a-id for prosecution under MG.L Ch.268,Section 1. Applicant's Signature:_�L__ - Date: /0 -?` f Owners Signature(or attachment)"7. _w; A ..',i./ Date: /0/0/r/at By: / ..G / Date: It Building Official(or designee) EMAIL ADDRESS: Zoning District Historical District 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 0 No J ,.f--9y ,.,.-Jr":7?:-- I F_;S TlI.AN 0 SO I f d-1.-.!_1 'I0ffice Use Only o,:y t M1 I GPdli 1 t l . t.'- ' 1. Pcmrit4 4',t 0 f r _ THEr "JTI rLINE A t.s aNlI. H ill I*Ai •)t i i 'I T i f r'I Ir)F.. ,AND Amount C\°`4.00:3�y f Permit expires ISO days from issue date EXPRESS SHED PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508)398-2231 Ext. 1261 CONSTRUCTION ADDRESS: ASSESSOR'S INFORMATION: Map: Parcel: OWNER: ( C',U"��l-.t7 6 CS_e "l, ...._.n/ Lug GJw.-.7. 'LT'. Jori 43C•- ?'t-i- ' NAME 1 vQ PRESENT ADDRESS TEL. 4 - CONTRACTOR: l �l.tg-�1• YN�'^.n.J �w�yy ��� J�1 �C 3) NAME MAILING ADDIaC TEL4 04tesidential 0 Commercial Est 3-Coo 1 Home Improvement Contractor Lie.* (fl©Cesq'3 Construction Supervisor Lie.* 13 2G1-fit-/ Workman's Compensation Insurance: (check one) 0 I am the homeowner .',ik_am the sole proprietor 0 I have Worker's Compensation Insurance Insurance Company Name: - Worker's Comp.Policy4 / SIIED INFORMATION New _ Size L JO x W 12 x H /0 Corner Lot: Yes No / . Per Town of Yarmouth Zoning Br-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 11 *The debris will be disposed of at: _ «.. I fit• - : - Location of Facility I declare wider penalties of perjury that the statements lie in contained are true and correct to the best of my knowledge and belief. I understand that any false answerts) will be just cause for denial . v. ntion of my ' _:d for prosecution under M.G.L.Ch.269.Section I. ) fir' Applicant's Signature: / Alrt� Date: /Q. ' e -I 'O Owners Signature(or attachment) t>s yz. 4.4411b..-tz-L_e,/ Date: t U' /211 90.s Approved By: Date: Building Official(or designee) EMAIL ADDRESS: ----- Zoning District: Historical District: 1 Yes fi No Flood Plain Zone: 'l Yes 17, No Water Resource Protection District: Within 100 ft.of Wetlands:*** II Yes C No El Yes 0 No • ***Note:Conservation review required if within 100 ft.of Wetlands 9/13 r __� The Commonwealth of Massachusetts p rm..= L7/ Department of Industrial Accidents le- _, N. Boston,Congress M4 02114-201 7 ite 0 • . E 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): Address: City/State/Zip: Phone#: . Are you an employer?Check the appropriate box: Type of project(required): 1.0 1 am a employer with employees(full and/or part-time).* ' 7. ❑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.] 3.0 I am a homeowner doing all work myself.[No workers'camp.insurance required.]t 9. 0 Demolition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my 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.p 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.❑Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] •Any applicant that checks box#1 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 ft 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 Sienature: Date: Phone#: 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#: .. .1 g• • it, • PLOT PLAN FOR LOT M Indicate location of garage or accessory building Additions with dashed lines Sewerage disposal (cesspool) ED Well isi I — _ Abuttor's I (lot ft. rear) 1 t — — ' Name I Abuttor' Lot N I Name I Lot A :f this is a REAR YARD :orner lot, ft. If this trite in name I corner if street. I write name of a IC. 9 other vro4I street. fo4 'Si: SIDE YARD HOUSE SIDE YARD a--- -.may 0Ero . I SET BACK . • • ft. . 1 4 1 0 (lot ft. frontage) / / (NAME OF STREET) information \ Supplied by (ARK NORTH POINT • Information and Instructions .. Idelekihtes Genoa)Laws chapter 152 require,all employin to provide washes'compmwdoa lbs their employes ' Puma*ls itS statute as aybyan Is dated ed ar's worry poem la the orrice of another under any mead a(hire express a implied,and or written." 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The affidavit should be '----in the shy a Iowa the,the appilarLe ewes permit a limes is Wag tem lose me the DISCOS of • Ward Amides Shaul yen ham agptessssepsdiegthe kwetryout arsgeldIs Moak 1worhee,' campeerlea pollee plass all lie Dsprtere d is woke Used bdoaa Ss)-lamed compacta shoal emir Thais salsa lime MIAS as the swamis lin Cay sr Ten Om.Mb Phase bee the the adidnb Is cook*and prised kpbly, The Deprtmet has ponied i spa a the bolos Mae aatdnb iter pas to dB out is the evert the Office a(lnotlptieshe ta cameo yesteendieg is wince Please beeramfill hathe prnahli- esiteswhichwinbemadasareamsscsnumb= headditive aapplicant the twat submit nada*petoiYUeer eappticsda.laaygiroyea,mudaslysubmitmea davisisdaatlegmires palsy kammit a(ifrrss.ry)and wake lob SSWAdams"Is appfirast abed wale•1n Saila is timer Arimy Mae e a*tlfes hasbeomaalymopedameheibyistyasprovided a appiaaeapied due svalid ailkdmvblotMeIter honepitman aIkea Awar s1Sdavkmast sMild out sack year.Wham a ba ns swam at cid=to ohtsh irg a Was a pearl m>Sad d to say bed's e a oro--W mama (Le a dog thanes or pewit to bon harm rte.)said pea is N07egdnd in samples this s9idsvit The oafs altare,iiptlrr weal like I dm*yen Is damp Am your mopaat as IS about skald you have say q.rione phase dl not hesitate M give us a cal. Ills Deprareafs Sane telephone sad ds mambas The Commoaweahh of Massachusetts Department of Industrial Accidents OAlee slkva4sdeae 600 Washington Shed Boston,MA 02111 Tel.M 617.721-1900 at 406 or 1-$71-MASSAFB Revised h 1.12aib Fax P 617-721.7749 %mein goy/iia ®r Massachusetts Department of Public Safety Board of Building Regulations art iStandams License:CSFA-060653 • :" Construction Supervisor 1 8 2 , It Family , CHARLES A HOLMAN j '" O MAY LANE t SOUTH YARMOUTH MA Onla 4 t:I1, ` •� "/�j.Lr04:40 /pa. . Expiration: Commissioner 03202019 \ J -,..7,.. .,-..Thr Oti� b kmo„«r/ ?jai- tira; .,' �- t / Y� Vi OSS 2 Gg °�� tip' ,$ ,��- I , 0445' cps 5 a �. LOT 24 0 10,705.2 f SF er P" SPOp . 1;00 \t -& if . . 30. .. 5%: °g id' fit ROBIN yz': 1 WILLIAMliA'(, WILCOX °' T-3 U N,0. 1 No.31341 x i abs ??..• iv 1-- • ,-"At 10'2.-1' TO THE BEST OF MY INFORMATION, "PROPOSED" PLOT PLAN KNOWLEDGE, AND BELIEF THE WEST YARMOUTH, MASS. STRUCTURES SHOWN ON THIS PLAN LOT24, PL.BK." 173/3 HAS BEEN LOCATED ON THE GROUND DATE __1071/18 SCALE 1° = 20' AS INDICATED. JOB 8100-00 CLIENT BELLA POOLS 10J1m18 , ��6%-- SWEETSER ENGINEERING 203 SETUCKET ROAD DATE PROFESSIONAL LANDSURVEYOR PO BOX 713 SOUTH DENNIS. rA X. 'SOB-3802880 OF Ft 508-385-13900 - FA5-699f C: 1 S8 1 PRAT 1 8100-00 I dng 18100-CPP.LNG 0 2018 SWEETSER ENGINEERING