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HomeMy WebLinkAboutBld-20-001039 ""'4�=� SHEDS LESS THAN 150 SQ FT SHALL BE Office Use Only �r� y PLACED A MINIMUM OF 30 FEET FROM THE Permiti •�. Via% �[k FRONT LOT LINE AND A MINIMUM OF 6 FEET t+ Amount ,01`PI eI FROM THE SIDES AND REAR LOT LINES 1`MA7TKF..Ct3e,¢, es' ; ,U" c Permit expires ISO days from °' issue date EXPRESS SHED PERMIT APPLICATIo --- _r�.. A - __.__...._� TOWN OF Y RMOUTH e Yarmouth °Building Department ' AUG fir; 2015 z P i 1146 Route 28 L. - ___ f South Yarmouth, Mr'1. 02664 �; t r (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: a 3 CR OWC.S ?LC e-cl14Se_ koc Q. Wes �a Alotzfk ASSESSOR'S INFORMATION: LtvADA A 1unEll Map: Parcel: owNER: NAieI A fkeceII ra ,3 CRowes ?urchale. RdL t`1eSr ,r,,,�,,,f� ?'18-I9© -(os37 NAME PRESENT ADDRESS TEL ri CONTRACTOR: _DR__ NAME MAILING ADESS TEL.# XResidential 0 Commercial Est.Cost of Construction$ (0trirb • V. Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) 1 I am the homeowner li I am the sole proprietor C- I have Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy# SHED INFORMATION New Size L x 17 x H Corner Lot: 1 •3 No • Per Town of Yarmouth Zoni,w By-Law Sec 203.5 E: Side and rear setbacks far 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 /4 x i /0 x H /C rE>rr *The debris will be disposed of at: Location of Facility I declare under penalties of perjury that the statements herein contained are true and correct to the best of tm-knowledge and belief. I understand that any false answer(s) will be just cause for deni r rcvoccatioo f my lice c and for prosecution under M.G.L.Ch.268.Section I.Applicant's Signature: "� Date: < t' 3- l 0�l Owners Signature(or attachment) Date:—0,?3 1 / Approved By:_____- �� ! Date: 0 Vta—1 building Official(or designee) EMAIL ADDRESS: Zoning District: Historical District: Yes l I No Flood Plain Zone: I Yes No Water Resource Protection District: Within 100 ft.of Wetlands:*** Yes .: No ri Yes No ***Note: Conservation review required if within 100 h..of Wetlands 9/1 The Commonwealth of Massachusetts 0. ='r G Department of Industrial Accidents =e"ram! 1 Congress Street, Suite 100 ok= EE_ Boston, MA 02114-2017 us. ' 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): L1144- -pu rce,(I 4,1�,n 114 %pce(l Sit. Address: a3 CROWeS at rrtols-e. RS- Wes 4- IA e..mot.k.i- . IAA Oalo 73 City/State/Zip: 065434Rfnoulfi (Y\1 4613 Phone#: C --L/90-- i/ • Are you an employer?Check the appropriate box: Type of project(required): 1.❑I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.[No workers'comp.insurance required.] 3. I am a homeowner doing all work myself. [No workers'comp. insurance required.]t 9. ❑Demolition 10 El Building addition 4 icer, 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.❑ Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.EI 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.t 14.❑Other Re?1QC� O1Q $h(9. 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 152,§1(4),and we have no employees. [No workers'comp.insurance required.] *Any applicant that checks box t 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. $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 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 ains and penalties of perjury that the information provided above is true and correct. Signature: 41...10-64 jiiizilli Date: O '93 "/cJ Phone#: 9-7E('(19a -G S 3- 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#: i. • PLOT PLAN FOR LOT # r 3 CRo(V S -Pusue Indicate location of garage or accessory building Additions with dashed rules Sewerage disposal (cesspool) Well isi I I f (lot 3 ft. rear) I Q Abutmr's Name 1'4 ')2 Feel- - I Abutbor' Lot Na'] I Name C ..owes PH R c{.�re Lot # f this is a IS et. �. Shea- c h P� REAR YARD If :orner lot, ft. this vrite in name a, corner ie street. I write i name of I Q. other 13 o street. , 4 SIDE YARD SIDE YARD ' HOUSE I d-- — —Jr-a- . • . • II. . . • . . . . • • . SET BACK . . Aft. I I V (lot ft. frontage) // C-k ow Es �i��J o se_ (NAME OF STREET) Information• Supplied by [ARK NORTH POINT • Information and Instructions •Mite Wane General Laws chaplet 132 requires aa.mployles to provide workers'compeuados fir their empleyess. Pursued b dda statute,as employee is defined NO-sag prow is the service of another under any Contrast oilite, express or oral or mitten" An ayLjrri.defined as"an iodividasi,prmrablp,asaociadoer compendia of other legal lily,or any two Cr mate at the heaping cep fiat he aieit saltepdae,sod haludleg the lop!reptw.asdres ode deemed empl.yw,or the reveler or twain oho ledMdasl,peels-ohig,reodLdos at odor lepel.edtyt,enaplryieg arployeenr 1 k,w.er the avast otsd rlliep hoses bevies net more then thee eprtmutb sod who seethe hawk or the occupant oldie dwelling haw olsmdt.rwho employs peers 1e de mehesees ..ooasltuados at repair wool on such dwelling haw or as the pounds ar bandies apperea lit throb shell sat because each eapioymrat be deemed b be as employee:" MCL drat 1l2,121C(6)she statue Weary stele or bail Ifsasriep sissy shall wMhh-Y the honors=r renewal eta Ueesse ar permit to operate a bedews at to a mi eat Wage in the eaoesweatth hrtr toy apparel she has set predated sseepthle alders of ampllesss with the Ieserasso average regehrad." es*"hes ray contrast ttl a the perhateu r pe6W,Meek=di aoeapetbbe widows eta patient���hshellal o ih cequiree net otitis chart have beat messed es the oearaedeg a utiodty." 0 °°e with the iosetree Applauds Please!flat the waders'000peaeetion Michell oomplalely,bysheebiag the boons that apply Is yes shears sad,It neasseen apply sibiartriere(s)" (.) del e.s(w)and phase aobr(s)shag with their ardfirett(a)al iansaaoa Limited Liability Compades(LLC)a Limbed Liability Pearahipe(Lip)with as aapleyese air then the nrmbre etpaean are sot required be any wartime co■rmaides leauasra Was LLC at LLP deal have aoptoyeeg a palsy is required. Be advised that his aetdavit one be abmtuad is dr Depeetmeeeot red terhi /midi the one dmaid as othe ersece coverage. Ale be awe le sip acid dab the affidavit. me slide*shield be seism!b the city artaws that he appl cedes meth.molter Bauer is bstsg reptaabej rest the Dspreme.t of • rndai,ldAM Shell yes have ay weeder regen leg the law ar Ityea ate ngnlred le obeli a washes' comps odes palsy,please ail the D.p■rdmaaa theameba listed bedew. Seilleasud cmepe■i.s should fear their sell1__-ee bane s■iet at the wards*pea CMy se Teem Omeids Please be ace that the affidavit Is complete sad Owed legibly. The D.partmsat has pevided spate at the bates ad*amdevil he yes to fill out in the*veto the Otfiee atray.sdgatios has is center you r.gsedles the epplieme. Please be nee Is ell Is the prrdlldeasa number which will be used me rsdraars morales, be eddidoq es applicant the!matsubmit meWpfe aeadrNass applieadoes l•ea tip yaw,and ady submit sae affidavit indicating come policy hhemedos(its.a..ary)rat cedar lob She Adams"the applies t eh.uld writ"oil loathes la (city or tower"A espy oldie affidavit diet hoe bentomdaity steeped or amend by the city as town maybe provided is the appllsea rpostdnt a valid addsvtt is as Ale he Atha weft at Seam A new elide*mat be dled out earth year:Whets a base MAW tit cid=Is abseiling a lama at pant ea mired to say bashers or eassaelJ aura (La:a dog ranee or penult b boo h eves me.)said pave is NOT r.gaied to complies this amdevk The Oats otlenadgdiara would like to Leask yes le advisee he your eeopoeadrs sod should yes have say gwsdone, plant de eat twelfth te give us a call. The Depstanrat'e edam.teiaphone sad the ameba The Commonwealth of Mataachueetts Depattmcest of Industrial Accidents olfta of foresdpdans 600 Washington Sheet Boston.MA 02111 Tel 0 617-727-4900 ext 406 or 1-$77•MASSAFB R Fax 1617-727-7/49 Revised t 1-22a1b v.ww.rnar.pov/dla r ,;