HomeMy WebLinkAboutBld-20-001770 .YqR Office Use Only
}O . Permit#
A.
...4. . Z' Amount,
s_33 , Permit expires 180 days from
,� issue date
EXPRESS SHED PERMIT APPLICATION
TOWN OF YARMOUTH OCT 01 201Y
Yarmouth Building Department
1146 Route 28 ;(C2
South Yarmouth, MA 02664 ��./
(508) 398-(2� `
398-2231 Ext. 1261
CONSTRUCTION ADDRESS: IS-1 Ems e-tie (RA IJ 4 N attryKo4.44-Ir1
ASSESSOR'S INFORMATION:
1 Map: Parcel: C<II
OWNER:Vftvi t'�t T+ &CIA•t m..Gt J r. 135 N ort„yoo cL A )e. RI, -ote% (M14 Con-SI 0----PSG'0
(NAME 1 PRESENT ADDRESS TEL. #
CONTRACTOR: S4$J.e..4 C Ay+rp 4 b-evei A
c
e_ P.. ,, i As pee WA co% _'117 _C,`dcac
NAME UU ADDRESS TEL.# "(h a Simi t, Pla,,ct
1/Residential 0 Commercial Est.Cost of Construction$ 4 550 • 00
Home Improvement Contractor Lic.# I 0 ail 1.d p Construction Supervisor Lic.# C S" O5(0 y to 5-
Workman's Compensation Insurance: (check one)
I am the homeowner ❑ I am the sole proprietor E?!I have Worker's Compensation Insurance
Insurance Company Name: hr1 W C.A P e 1 elko tit ti Worker's Comp.Policy# W L"4 7 $8 a O•a,-3 — t 9
SHED INFORMATION
/,' w Size L a, x W 8 x H 1.S 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 G, g x W $ x H $ '
`
*The debris will be disposed of at: r 0.erw.a l.a.v& t\ OU►pc»cal Preen.. — J`Qiy�1T" t V‘.��T 0'�"�t�e-�'-G •
Location of Facilky J
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 or re ation of my license and for prosecution under M.G.L.Ch.268,Section 1. a �1 a
Applicant's Signature: Gam. Date: —Q1 ' aA / l
X Owners Signature(or attachment) Date: t rl — ,q
Approved By: Date:
Buildi ff ( designee) MAIL ADDRESS:
q o__C�_4._ ob4y.c_o w1
Zoning District:
Historical District: I Yes No Flood Plain Zone: 1 Yes [ No
Water Resource Protection District: Within 100 ft.of Wetlands:***
Yes I No ❑ Yes I No
***Note:Conservation review required if within 100 ft.of Wetlands
9/13
Oct 01 2019 102310P1 HP Fax page 1
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Oct 01 19 04:250 Default 0123456799 p.2
- The Consummate*of Massachusetts
-_ M.--, Depart t a/Dean:rink!Aeefdems
_:_�'i
l Congress Saito 100
,MA 02114.2017
Workers'Coax w ass.g.1dda
penaatlon Iaarsooe Affidavit:Bdlders/CoatreeOerslBiaMeisaa+Plambers
TO 8S FILED WITH T y PEBIGTTBIG AU1110131TY.
itealisimbacums______ Pisan Print Look&
Name ca adodlnm ` - �yideal): [ mtti Gr—Al t l..J«i
Address: 1 C 1 E>I,[rash_ ce7
Csty/State/Zip: ti#1.4460,1 F Phone 1k: (e l7 S9 O 7%I o
A is you ea sispis.rt Peek dims appropriate leis
t.[]1asscaplaycrwitl smplcyars( [,,Egos • •
Type of project(nsgaired)c
2. I is ssola Pn•Qasf. 7. New construction
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Nr fib.l)�wmilas'eoiep.iwasrse raetarbad.) a• ❑RsroOdlling
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s.®I anahoasorasr Pad sill ha hiring oericsetoo is aoaduq ail enact an nay praDeey. twill 10 Q$nildias addition
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proob ogyna aompsoys.. rspeils eredditinAs
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Ids atlas elladad d .0 per n or additions
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13.�]Roof rapdas
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meth
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log an employer shish pro wormers'ese pe oidion icaesuioeee for no earlogrows. aglow 10 the policy Pact ja b sits
Worm*Company Ne m -134rOCt-ett
Policy 1f or Sel•ins.Lie.If: . - 4-7 86 Pb 1 - 3 ►19 F.xpbasion Dade: 8 • z1.•2-es
fob She Address; IV, elf c-Lr a*e"t. _Ci IStaimti :la Nofn owner NI ei 01 sirs
Attach a capy.f the works,'eeiapaoaedoa pow declasafyoa page(1row ig tea policy inunlier and mention date).
Facture to secure coverage as required usderMOl.a.132.f2SA is a miming violation punishable by a fine up to S1s00.00
and/or one-year iarpriaoomeat,as well as civil penalties la the than of a STOP WORK ORDER Pad tans of up to 32S0.00 a
day whist the violmr.A Dopy cftbis strpo Meat may be forwarded to the Office of laysstipdppa of the DIA for k:aurauoe
non+ verification- • ,iiia
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Sianntor
phone* Sog- y —(0 ; : Dote /d l/�
coda saat onbi. Do notes*be this ores to be completed by eke or roewrr official
City or Town: PSraaWl ioemss E
losing Astkodty(circi.ass)c .
' I.Beard of tiealtb Z.Bundles Depactoalat 3.City/Tows Clerk 4.ElectMtlll Inspector S.Plolfabiag impeder
6.Other
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