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HomeMy WebLinkAboutBld-20-001872 SHEDS LESS THAN 150 SQ FT SHALL BE Office Use Only ‘ FROM PLACED A MINIMUM OF 30 FEET THE FRONT LOT LINE AND A MINIMUM OF 6 FEET Yemtit�+ {Oi - " • 1 5 .4 FROM THE SIDES AND REAR LOT LINES A170unt Permit expires ISO days from issue date EXPRESS SHED PERMIT APPLICATION TOWN OF YAIIOUT1-1 Yarmouth Building Department l L1i:i 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: I (9 Z ( 4 C D ASSESSOR'S INFORMATION: Map: Parcel: OWNER: rRAvgK 0IlvCl,ebA ) c Ttua-tCNo_ R fl 77q- 6.1 SO NAME PRESENT ADDRESS TEL. # CONTRACTOR: R A p,1✓C 1�A 5._r' ►m P-S A-fl©✓� NAME MAILING ADDRESS TEL.# t fi sidential 0 Commercial Est.Cost of Construction$____ O Cj Rome Improvement Contractor Lie.m J l 2 1 3 Construction Supervisor Lie.# Workman's Compensation Insurance: (check one) dam the homeowner 0 I am the sole proprietor r..] I have Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy# . / SHED INFORMATION V. Size L x W x W eD Corner Lot: Yes No Per Town of Yarmouth Zoning Bye-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 Pk" x H *The debris will he disposed of at: Location of Facility I declare wider 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(si will be just cause for denial or revocation of my license and for prosecution under M.G.L.Ch.268.Section 1. Applicant's Signature: 1'rZ/( vP�v Date: / 0 1�— Owners Signature(or attacfunent) CC Date: , 0 - 1 Approved Date: Building aal csignee) EMA L ADORES'. Zoning District: Historical District: Yes ". No Flood Plain Zone: Yes f. No Water Resource Protection District: Within I00 ft.of Wetlands: Yes No Yes hn ***Note: Conservation review required if within 100 f1.of Wetlands 911 r . The Commonwealth of Massachusetts /, Department of Industrial Accidents (,=Nall- 1 Congress Street, Suite 100 E4 Boston, MA 02114-2017 ....•s`� 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): , t o/I v'l izA Address: 1-62 T 11-A--Z-c µe p 1,? b ]. City/State/Zip: Sd Lit- y- y 4_?..vh 0 v614- Phone#: '7-74 — 2-7 —6( S a 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. [ lew construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling a y capacity.[No workers'comp.insurance required.] 3. m a homeowner doingall work myself. t 9. ❑Demolition y [No workers'comp.insurance required.] 10 0 Building addition 4.❑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.['Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.El Roof repairs These sub-contractors have employees and have workers'comp. insurance.: 6.D We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q 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. $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 certif under the pains and penalties of perjury that the information provided above is true and correct. Signature: "� /,� Q -- — ( q / ��%� Date: 1 � 1 t� 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#: • e4 PLOT PLAN FOR LOT # Indicate location of garage or accessory building Additions with dashed lines Sewerage disposal (cesspool) ED Well. 42/ I I - - - _ I (lot ft. rear) I Abuttor's 'fl• —' — - Name I Abettor' Lot # f („ Name \f' r Lot # this a 3UREAR YARD :ortner lot, ft. If this vrite in name I corner >f street. I write i name of •0 Q. other , b ,� street. 4 • SIDE YARD SIDE YARD • HOUSE . • • • • • • • • : SET BACK . ft • . I -"1 I (lot ft. frontage) / (NAME OF STREET) Information / \ Supplied by LARK NORTH POINT