HomeMy WebLinkAboutBLD-19-002876 • ;:.-ir-}.: ).ES 11 IAN 4_ FT :':H.-:L
J > >' "� t Office Usc Only
.01. r Mtili.A tlr ,
'? " �O r I THE1(' I ( r FINE .?0`.:C.: i Permit"!
Q .�.�e,V� C "411‘..1#11),,r)t *-IC.T FROM OM '111 /.vC/ !Amount
;Permit expires 130 days from
`-<••- ;Issue date •
a_D-ic1-f &76 •. E C E I V E D
EXPRESS SHED PERMIT APPLICATIIO
TOWN OF YARMOUTI-I NOV 09 2018
Yarmouth Building Department
1146 Route 28 BUILDING DEPARTMENT
South Yarmouth,MA 02664 By'
(508)398-2231 9 (�EExtt. 1261
CONSTRUCTION ADDRESS: aL.--1 fehrckek Ra . c(Qtj^p„tooU r4.
ASSESSOR'S INFORMATION:
Map: • Parcel:
OWNER: Cay fiAhro 4le!re ivacPRESENT a 4z4 . liarr.tart{.PorRE + S2
. 2- 2g0-x662—
NCONTRACTOR
•• NAME MAILING ADDRESS TEL.It �
''Residential ❑Commercial Est Cost of Construction S 3001, - 60
Home Improvement Contractor Lie.# Construction Supervisor Lie.#
Workman's Compensation Insurance: (check one)
i1 am the homeowner D I am the sole proprietor 0 I have Worker's Compensation Insurance
Insurance Company Name: Worker's Comp.Policy#
SITED INFORMATION
New V Size L Ii x W (O x H Corner Lot: Yes Nqe‘c
Per Town of Yarmouth Zoning By-Law Sec 203.5 E:
Side and rem'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 H
*The debris will be disposed of at
Location of Facility
•
1 declare wider penalties of perjury that the scnements herein contained are true and correct to the best of ray knowledge and belief. I understand that any false answerts)
will be just cause for denial or revocation of my licensenand r prosecution under M.G.L Ch.263.Section I.
Applicant's Signature: W Date: It [ ' I()
!Owners Signature(or attachment) ��' ..r./ Date: ` ' q ' II
Approved By: , .,�(-,� Date. ` L - i e
Building Official(or designnee) EMAIL ADDRESS:
--
Zoning Distric _
t
Historical District: 1 Yes n No Flood Plain Zone: Yes G No
Water Resource Protection District: Within 100 ft.of Wetlands:***
Yes C No (1 Yes '3 No
• ***Note:Conservation review required if within 100 ft.of Wetlands
9113
,r
The Commonwealth of Massachusetts
/, • Department ofIndustrial Accidents
iel_ s, 1 Congress Street,Suite 100
F_ � Boston,MA 02114-2017
"9 www mass.gov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
J Name (Business/Organization/Individual):193-et5nc TSAICAde_
Address: aZ 9 Sc 1-vcfte i- kd--t
City/State/Zip: { P—�enA 02fo75 Phone#: So$-2so- O(o_A2. •
Are you an_employer?Cheek the appropriate box: Type of project(required):
1.0 1 am a employer with employees(full and/or part-time)." ' 7. 0 New construction
• 2.01 am a sole proprietor or partnership and have no employees working for me in S. 0 Remodeling
any capacity.[No workers'comp.insurance required.]
.p- 3.27 am a homeowner doing all work myself[No workers'comp.insurance required]:
9. ❑Demolition
4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 0 Building addition
ensure that all contactors either have workers'compensation insurance or are sole I1.0 Electrical repairs or additions
proprietors etors w tit no employees. 12.0 Plumbing repairs or additions
5.0 I am a general contactor and I have hired the sub-contactors listed on the attached sheet 13.0 Roof repairs
These sub-contractors have employees and have workers'comp.insurance.: f-
6.0 We are a corporation and its officers have exercised their right of exemption per MGL e. 14.at-Oilier P rLn.�
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
•Any applicant that checks box#I must also till 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.
:Contractors 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 MOL 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$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct
Signature: /'/ — c✓Ij rR fes Date: (1 ,2� •($'
Phone#: Sb:— 230 - 61,4 2—
Official
Official use only. Do not write in this area, to be completed by city or town official • .
City or Town: Permit/License it
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#:
•� PLOT PLAN
•
..• 9
FOR LOT q
Indicate location of garage or accessory building
Additions with dashed lines
Sewerage disposal (cesspool)
Well 1:gj
I
' (lot ft. rear) I
Abe-utter-1s— 'fl' — — —'
Name I Abutter'
Lot M _ Name
REAR YARD
:f thisisa Lot
other lam, ft. If this
vrite in name i corner
xf street. ( write
7:"64, name of
Ti a other
"aa v street.
4.
. SIDE YARD
HOOSE SIDE YARD •
.
.
•
SET BACK ••
•
•
0
(lot ft. frontage)
S
/
\ /
/ (NAME OF STREET)
Information
Supplied by
IARK NORTH POINT
N
•
Information and Instructions I ,. : •
taeSn
bfnrsa Omni taws ohtpwr 132 require all employits to provide'radars'wmpeoaadcs dr their=ploys
Pura=to this sun as byte It defined n•..•nay paras is the write of samba under say contract albite.
some ae Stied,oral at ratan
As esgieja is defined se as mdhidnal.pasmsahip.=dad carpondcs as other bpi entity.or nay two at mora
of the thnpiog engaged is s Jail Sep*and Includl the kph repteteatadvet ofs deeassd empbs,or the
race=r or Mae olas odldds4 pataasshtp sendedos an athar legal adtA employb fi auglge% IL.....the
own oh dwetlbg hos having not mon than that apaatmads end who resides thtaai.,at the accost a(5
dw=Weg bows Washer who ender puss de earnesemar canasta at repair walk as sock dwelling hones
at as the ponds or building apparent dm=deli not beaten of suck eagioyasat be deemed to be as employe:'
W.chaplet 132,125C(6)abs stars the'Sas athae ate hal Ikea(ages shall withheld de Issas sr
rand of lines sr permit t.speak abelsaofirbenarl selbandbpisthe& —...wiled sane
appals!was is set petted septet aides of templssw wile the Isms comp rifled?
Additionally.bid.tree 131,J23C(7)Min'Wean the aasosenith ea say of int pnl"nI madlrbbs sera
este fors nay canna Ibt the pets=of pills work omit aartarb evidence afeampitaoa with lbs hasaaace
requktsmr of this chapter have bees praansad as the contracthep shorty"
Applies, •
Phase fill at the setae'cases= completely.by checideg the boars that apply o year Sedge and if
oaeaaer,,!apply subwetraaea(a)swa(s),adAes(e)and please esba(s)done win Sit cetitims(d of
h.---. Lhdted MSS Caqudes(LLC)a LAMM Liability Padips(112)with en eagle pus NS lbs the
numbers orpetaas an eat toed to carry nine'commandos hose—.. Its LLC a L I doss his
employees,a panty is regahad. Be WSW St this affidavit sty be:Maimed eo the Deprtmevi at India=
Anklet Pot ceememtios of L_.....coverage. Abe be sen le sip and date de affidavit. 13e affidavit should
be anned se the city at lows die the opplicatios flo die pewit ar Hose is bag ropmeed est the Demonsof
•
isbethdAt'.ns 3h' Id sane say sneer reprise the law at ifyos as ngaid s abides waken'
co peendspdell y.pSadtheDop s etther mbaIWidbeow. Saltines=comp=snit else their
seldnesses Sees amber cede swan=Brew
City we Ten DOhob
Phase be ate that S affidavit is camp=sainted legibly. lb Departs ha provided:space et the bows
otthe afitit Isom to aut is the even the Cake of larestiption Ms coated yam regarding applies%
linos be rte 1s fill he the penanlicease ameba white will be and as a aim=®bee. Is addition.as mg Prat
Mt_Sur=tip P.®ivtimse spruce's Is any give year.need Spar= at=Indicating wens
podgy Sanwa ad mkt lab SIM Mean dm'pelican draw write-an bans o
tows)r-A copy oldie ad'Idnit diet hs nee ofikis y stamped vee mead by the o r So a
sty my
appncaetnpent deg avalid aid=iscmfile kir hem sae ak aas Asaw affidnitins befined ateaJ
yew.When a hoar maw atchime le obtainer a names arab not missed today bed=aooamaeW venture
(Le.$dog nares or permit as baa Invos a)said pesos is NOT ngahed te compile di affidavit
11a Odin of Isvadpfos waned like l thank yes le adrenal in yaw coopeayos and should yore hare say cake n,
Melee de net SSW to give s a at
The Drepemeat'a address.wk$....sad As somber
The Commonwealth et Massachusetts
Deportment of Industrial Accidents
Once of lttvetdlptfau
600 Washington street •
Boston.MA 02111
Tel.0 617-7274900 tot 406 or 1-877-MASSAFB
Revised 1 t-u�i` Fax/617-727.7749
www•anaat.etar/d1s
•
I • 414.Y
TOWN OF YARMOUTH .
� . RECEIVED
r= r 1146 ROUTE 28,SOUTH YARMOUTH,MA 02664-4451
Telephone(508)398-2231 Ext.1292-Fax(508)398-0836
OLD KING'S HIGHWAY HISTORIC DISTRICT COMMITTEE
3 2018
++ YAKtviUUTH
• APPLICATION FOR OLD KING'S HIGHWAY
CERTIFICATE OF EXEMPTION
Application Is hereby made for the issuance of a Certificate of Exemption under Sections 6 and 7 of Chapter 470 of
Acts of 1973, as amended, for the proposed work as described below and on plans, drawings, or photographs
accompanying this application.
Type or print legibly. �J y�V�
Address of proposed work /2./9 ‘c v/l4- gel• eirr Rd' Map/Lot# 1f
45
ownerfs): �7/1hw.s(� / Phone#:SoQ. a $D-6662,
All applications ust be submitted by owner or accompanied by letter from owner approving submittal of application.
Mailing address: 2-14 to fi.cKek Ra-. qe fw.nt k& ti- ort Year built (4g0
Email: /1it16(144 e1�{/�l.�. Alk l / Preferred notification method: Phone r/"Email
•
Aoent/CoOntractor. JJ Phone#:
Mailing Address:
Email: Preferred notification method: Phone Email
Description of Proposed Work(Additional pages may be attached H necessary):
A f o1 r)IN (2J .5,041. (Q-,( ) Pa[ s drorccA at^— 1
• 07 (d1`1 d ?Air.teA.BTU Ma L Lo Cttp o(a—.
• 1 r (A1tl l 410 (v`-1'O MaS k•f p i o✓�'.Oan c-'s i- o-J
J U, n�� �itnG�cSPO-�V�nSorc�� .
Signed(Owner or agent): �u,r�,.r . �6'1°f Date: g• 23• IIs
> Owner/contractor/agent Is aware that a permit maybe required from the Building Department(Check other departments,also.)
> This certificate Is good for one year from approval date or upon date of expiration of Building Penna,whichever date shalt be later.
For Committee use only:
Date ��3- =Approved _____Approved with changes Denied '
Amount 96 Reason for denial: {,, _ APPROVED
CashlCK>t 01511 1\I-..GEiVcD
AUG 2 4.2018
Rcvd by. t2W AI IG 2 4 2018 YARMOUTH
Tntnrt•trlFRV OLD KING'S HIGHWAY
SOUTH YARMOUTH, MA
Date Signed:iF/Lrzr'/3' Signet V/f 6C. APPLICATION#: I k- n)S•R
V32017
° r _ - . .. b. 1145- 4AtCo
-o /may________R.,:,
moi , > -z she Mir 1_3. 7
.y - '� }If 11 m Q� -Q • `- ♦. --.--
1 Lli ^ H m I
. W- a ' Y o W Ocr La
} CoQ 1'•4? GY �=j•
IIS • ICE cr ¢ Ft 4. Om O ;
to
-if.` - _1t_
CO • )�•� e
a CO
— 9a�
• �' o
v o Q f r .4 *,SS 1 Q O u0 V N
N c Q e0N • Z h
u% a �c� t
V
• I I-.1 ! • o zi.! 1;ig�• •
J I .a
J q 1.%vS3 J
1 i 4 N tiQZ4RQ NI
Ai
. 4 .`U Z • tiQ vku
•
• �' - U %/ • yMI- Oc •. • J•