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Permit expires ISO days from
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EXPRESS SHED PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building DepartmentP 1 2019
1146 Route 28
South Yarmouth,MA 02664 -
(508)398-2231 Ext. 1261 l l
CONSTRUCTION ADDRESS: cl SO - 7CL.f'"rvt._p 044. c 244
ASSESSOR'S iNFOItMATION:
r�7• Map: Parcel:
OWNER. &ii1- ( cJS"�
,` 'ENT ADDRESS TEL #
CON'fRACfOR i iPOCY.4 t11)C� PYr�l i Ove-cn Alec R.d V436 284(�
NAME MAILING ADDRESS
L Residential 0 Commercial Est.Cost of Construction S 5)10�o. °
Home Improvement Contractor Lie.# 3a 9 S Construction Supervisor Lie.# e c}A O-.3 S LP
Workman's Compensation Insurance: (check one)
D I am the homeowner D I am the soleproprietor KI have Worker's Compensation Insurance Q
Insurance Company Name1.�r� rnFt�;{Q 2f S L. Worker's Comp.Policy#EC C C CO q GQO 1'31 -7415:0
SHED INFORMATION
New 1< Size do o x w 0` x 11 t/ [ Corner Lot:Yes V 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 6feet in all districts, but
in no case built closer than 12 feet to any other building.
Replace existing* Size L x W 11 ll
*The debris will be disposed of at: l Q•e ifA A C�(1Q, G1. l v.�i C� M� 02(9(5
Location of Facility
I declare under penalties of perj ,• that' 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 mince for denial „ f my license and for prosecution under M.G.L.Ch.268,Section 1. II p
cti
Applicant's Signature: /.l _I _ — Date: l I 1 1
/Owners Signature(or a (Chiliad) .� � 4 f%. WP 4/N1%_ Data: I t t 11
Approved By: i� Date:
Building Official(or desi. )/ EMAIL ADD `.S:
Zoning District:
Historical District: 0 Yes D No Flood Plain Zone: D Yes 13 No
Water Resource Protection District Within 100 ft.of Wetlands:***
0 Yes 0 NO Li Yes ` No
***Note:Conservation review required if within 100 ft.of Wetlands
9/13
ur+u8iZU18 12:40PM FAX 18084301115+ • PINE HARBOR Qb0O01/0001
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The Commonwealth 0fhfaeaa� •
Sidi_ Department ofl�lAccidents
--`_t 1 Con$^rssSh�ett,Suite It?Q
= - Boston,MI tlZII Z017
WPM/01407.galitila
Workers'Compensation Insurance Affidavit Builderts/Contra
TO BE FILED WITH THEcm/Plbers
y 1,1 1 PERMITTING AUTHORITY.
-• - fl.:l• �iLl
Name(8u3ehJOi oollndividual): Ad �`0 at LeriMv
__----
Address:
CitY/State/Zip:
415 Phone it
Are yen ash fin"Cheek the appropriate bat:
I•Q l not a employer with�,_ yets. (itdl antlerpp j. Type of project(required):
� r'4' (No workers' and
have no employees woekiaj 0Or. mo�ipi *� 8. ❑Rem delingconstraCtiast
n P.mnuaaae required.] S • •r $. Remodeling
3.01 am a ner doing all myself.(No waiters' required 1
rep.iR+ah�ce ► 9. • Demolition
4.0 i am a homeowner and will he hiring co n to all wont on my Property. I will ❑Building addition
ensure that all eonhraetors either have wnrltro' •
10
proprietors with no employees. compensation c or are sole 11.0 Electrical repaint or additions
3 Q i soma contractor and i have hired duo listed on the Macho!sheet.These 12.Q Plumbing repairs or additions
sub
have employees and have workers'comp.insurance.: 13•❑goof repairs
6•0 We are a corporation and *Mors have end their or 14.CJotb er
152.11(41 and WC have no employees.(No workers'comp.insurance
won e�hdaf.e.
itwraneeroquittd.j
t*Any
applicant
ers who checks
ubmit btox Ail
must
also Gil out the eooden below showing their workers'compensation policy orb
tonna:rots that check this box must additional sheet indicarig they arc doing all work rod than hire a soho contractors must submit a new not suet_
emplmPlayc g� havehowing the�oome nee state whether or not those entities have
..r.---�— ° .they mutt provide their workers'comp.policy nuhaber.
I�thaw is providing workers'cow i r r forwgr m� Below fs theMiry 1�, e
Insurance Company Name:AbAdlampstikanOsasjnstj
Policy#or Self-ins.Lic.1l: -
.FaCC1a0t)-yirea57-�t$A Expiration Date;
Job Site Address:
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 S1.500.00
and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK RDER and a fine of up to S250.00 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. A
Pli "' se rp " ° ap ed niovr tree and correct
'qt.:A Al-- Au / WWWII F
use only. Do root write br tkk to be completed by city or town o, =Ur Air
dd
City or Town: Permit/License#
i Authority(dr le one):I.Board of Health i Building Department 3.City/Town Clerk 4.Metrical
Inspector 5.Plaything Inspector
Contact Peres: Phone*
•
44 • PLOT PLAN
- ' P.
.. '
FOR LOT
indicate location of garage or accessory building
Additions with dashed lines
Sewerage disposal (c essP«ol)
411)
Nell 0
I
._ , ...N. !t. rear) J
MUMAbuttor
( 1t 4 .
Lot N I Aautto�r
r Name
Lot
1` this is a / REAR YARD
/
�os-ner lot, \ If this
trite name 1
t m ft. _
met.
et.
• I, welts x
name of
other
,o street.
if
ti
SIDE YARD /
•
HOtJSg SIDE YARD •
0 a
w.
•
.
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.
I :
• SET SACK \•
•
.
.
.........ft. •
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V.
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(lot. .... ........yt. __"'ag )
/
MANE OF STREET)
/ f`
/ \ Information
Supplied by
ARE NORTH POINT