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HomeMy WebLinkAboutBld-20-000158 Alt <O i Ce Use OnI O y Amount ?,47.. ' c Permit expires 180 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: /7 C'YE'F//K Q Q WE S mot 7-1/ ASSESSOR'S INFORMATION: ''11 Map: Parcel: OWNER: I/) Tip' yNl? BCrC1 ✓ s08•ZZ >• i/96 NAME PRESENT ADDRESS TEL. # CONTRACTOR: kVER,VA/ALEXAA14Ra f�LC� L t/ 40/•6S ?` 77 NAME MAILING ADDRESS TEL.# 00 p Residential 0 Commercial Est.Cost of Construction S /©a e, Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman'5.Compensation Insurance: (check one) 1-94 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 New Size L /S x W '0 x H Corner Lot:Yes No 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 L x W x H *The debris will be disposed of at: eV E y'A Location of Facility I declare under penalties of perjury that the statements herein contained are and correct to the best of my knowledge and belief. I understand that any false answer(s) will be just cause for denial or revocation of my license: `for prosecutio under M.G.L.Ch.268,Section 1. Applicant's Signature: ' Date: Owners Signature(or attachment) t • (PAY -�'"" Date: 74 Z 0 / Approved By: Date: Bui (or esignee) ADDRESS: , orn U Be-cc v( 641,1/L.C E7M Zoning District: Historical District: 0 Yes 0 No Flood Plain Zone: 0 Yes 0 No Water Resource Protection District: Within 100 ft.of Wetlands:*** ❑ Yes 0 No 0 Yes 0 No ***Note:Conservation review required if within 100 ft.of Wetlands 9/13 The Commonwealth of Massachusetts '/ Department of Industrial Accidents _::a 1 Congress Street,Suite 100 -W ' Boston, MA 02114-2017 - www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): A2E X/M14 /2// &f cC / V Address: /7 C/-/Efyl R F_ /D City/State/Zip: y,4P pp,d / Phone#: 40/ ‘S- • 7 7 y 2 Are you an employer?Check the appropriate box: Type of project(required): 1.01 am a employer with employees(full and/or part-time).* ' 7. 0 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 1 am a homeowner doingall workt 9. ❑Demolition myself.[No workers'comp.insurance required.] 10 ❑ Building addition 4.0 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.❑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 sub-contractors listed on the attached sheet. 13.Q 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 He D 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. 1Contractors 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: /7 C/1ECNJ/ ,5 deD City/State/Zip: w/sr YA�/u0(�TL1 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 certtfy under th ains d penalties of erjury that the information provided above is true and correct Signature: Date: 7` d/�/ � 9 Phone#: 401 ‘S-q 774 z 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#: -A• "s ue "6214 1D/112016 CerGRCale�rY"?'�e . Assessor's Map 31 Blk: Lot 20 Census Tract • MORTGAGE INSPECTION PLAN Scale: 1"=40' 17& 19 CHESHIRE ROAD, WEST YARMOUTH, MA 4iV3 �� N/F POLLOCK I4 _ ___— 114.57' 71 LOT 79 i n j 13,603± S.F. v1 ` i i _ DK II�'-- 1 J I mi N/F ELLIS. LOT 78 ,r I *17 #19 of lcn i i j Q= i> 1 4 .. • °• . DR DR I ij � i f 108.34' • CHESHIRE ROAD 1130 . CERTIFICATION I CERTIFY TO THE ABOVE ATTORNEY,BANK,AND THEIR TITLE INSURANCE COMPANY THAT THE MAIN BUILDING,FOUNDATION OR DWELLING WAS IN COMPLIANCE WITH THE LOCAL ZONING BYLAWS IN EFFECT WHEN CONSTRUCTED(WITH RESPECT TO STRUCTURAL SETBACK REOUIREMENTS ONLY)OR IS EXEMPT FROM VIOLATION ENFORCEMENT ACTION UNDER MASS.GENERAL ' ^ . ' " ----' r-~-�� � ^ , . ' r ' r eV' • PLOT PLAN . 27 FOR LOT I 't Indicate location of garage or acces b Additions with dashed lines age disposal (cesspool) Nell is I Si A/e7 ,d rfv.� I (Lot ft. rear) Abutter'•s MINN •Mal0 MEMO =Om. 0 — — -... Na I Abuttoor' Lot I Name I Lot t it this is a REAR YARD xxner lot, ( ft. If this trite in name 1 corner street. I write ii r ' I ,* name of Iother st set. 'i . • ---4211 SIDE YARD czN 8d � E YARD_, . _.. . _..EIS . . SID . . . . ? • . I . . I . . . SET BACK • so t} I I a (lot ft. frontage) 0 4.4 y'e__ co • / (NAME OF STREET) (....... / s► Information le)c1/)i> /�► & c` Supplied by IK NORTH POINT a < ANL!