HomeMy WebLinkAboutBld-20-563 SHEDS LESS THAN 150 SQ FT SHALL BE Office Use Only
PLACED A MINIMUM OF 30 FEET FROM THE Pernrit# _
FRONT LOT LINE AND A MINIMUM OF 6 FEET _
ot.- s i yY FROM THE SIDES AND REAR LOT LINES AmountL�
MA7TACF.
Permit expires 180 days from
issue date
t -b—W-50
EXPRESS SHED PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28 C �
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1.261
CONSTRUCTION ADDRESS: "l / (. Q,l�. 11 L'� `kkriuot-k CY\-C\
ASSESSOR'S INFORMATION:
Map: Parcel:
OWNER:OWNER:., exi-As.Q`` IN `y \) ' �yUn ,
Se
NAME PRESENT ADDRESS
CONTRACTOI A S ,S 5 3' _ �A,^QE� S° d �N S t4QO
NAME l MAILING AD RESS TEL.
Xl Residential ❑Commercial Est.Cost of Construction 9
Home Improvement Contractor Lic.# `�S 35 c Construction Supervisor Lic.#
Workman's Compensation Insurance: (check one)
1 I am the homeowner E I am the sole proprietor C:i I have Worker's Compensation Insurance
Insurance Company Name: Worker's Comp.Policy#
STIED INFORMATION
New X Size L I y x W 1-6 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 x
*The debris will be disposed of at:
Location of Facility
I declare under penalties of perjury that the staten ems herein contained are true and correct to the best of my knowledge and bell'f. I understand that any false answer(s)
will be just cause for denial or revocation of •It and for . c on under M.G.L.Ch.268,Section 1.
Applicant's Signature: i Date:
Owners Signature(or attachment) Date:_.____.________
Approved _._ Date: 7 16)
Building Official(or designee) EMAIL ADDRESS:
Zoning District:
Historical District: Yes No Flood Plain Zone: Li Yes No
Water Resource Protection District: Within 100 ft.of Wetlands:*"
Yes No 11 Yes No
***Note: Conservation review required if within 100 ii.of Wetlands
9113
_� The Commonwealth of Massachusetts
►�_ !/ Department of Industrial Accidents
=e_= 1 Congress Street,Suite 100
Boston,MA 02114-2017
www.mas&gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Lesibly
Name(Business/Organization/Individual):Salt Spray Sheds
Address:235 Great Western Road
City/State/Zip:South Dennis, MA 02660 Phone#:508-398-1900
Are you an employer?Check the appropriate box: Type of project(required):
1.Q I am a employer with employees(full and/or part-time).* 7. El New construction
2.❑I am a sole proprietor or partnership and have no employees working for me in 8. ID Remodeling
any capacity.[No workers'comp.insurance required]
3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. Demolition
10 Q Building addition
4.EI 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. repairsRoof repairs
These sub-contractors have employees and have workers'camp.insurance.:
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c.
14.QOther shed construction
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 certify under the pains and penalties of perjury that the information provided above is true and correct
Signature: Date: 07/13/2019
Phone#:508-398-1900
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#:
y •
PLOT PLAN
•
FOR LOT #
Indicate location of garage or accessory building
d;ng
Additions with dashed lines
Sewerage disposal (cesspool) 69
Well. isi
I
IY� (lct ft• rear) `t
Abuttor's 7 'fl• _ — _ -
Name Abutbor'
Lot # I Name
-) Lot #
f this is a REAR YARD Lta
:currier lot, i ft. If this
corner
trite in name I
If street. write i,
I
name of
11
0. other
13 ,� street.
4
: SIDE YARD
• SIDE YARD
HOUSE .
q-- - -•.ET= 0 q----- '0
.
•
. SET BACK
.
.
ft
I
3 D (lot ft. frontage) O
/ (NAME OF STREET)
Information
/ \ Supplied by
[ARK NORTH POINT
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Information and Instructions
�t Oeeaal Laws chapter 132 sequins all employing to provide wadma'composedoa hr their smployoa
Pursued tt tide statute.as employes is defined as"...sway person is the service of another under any connect(White,
express or implied,oral or madam."
As esgkpris deiced as"as individual,paloeabdp moeiedoe,copulation uation at other Ispl malty,or any two or mote
oldie hoping aimed in quiet eateepries.and Wades tit legal np esaaodvse ate dme■sod mph's%or the
receiver teen en ohm iedlv'idselti po omaldpl asortstion or other lop!adty,empleyisg em pheyeta lases the
owner ofadwdliep hoots bolos not mote then those apeomm a=dwhe neidee at the aoeapeas of ibs
dwelling Lowe ofaewhst who miploys prams b de meiassaenco.eoaeesction ormph work on suck dwelling hors
or as the ponds or building sppertamot thump shell not basis otsock ea oloymsnt be domed to bean=plow.°
MCIL chop r 152,I2501)Me stem that"awry ems at Ind d least a sway sksl withheld the knew or
renewal eta Skeen ter permit to swan a heelers or to command building he tit commenwesIth be any
sppWteel wile hat sotprsdead aessptehis aldo a ettempllemse with the teeeraeee Beverage rspml s
Addides ally.PAOL chapter 132,1111C(7)stems'Thither the commonwealth cot any or its political sabdtvWaseshall
esaist date say contain An the palieaa■eoe Opole walk u nil soeeptablt evidence eteaayttmse with the tossmaece
requirements olWle chapter have bee prwantsd to the coettesdng sedhwityr."
Apptlesne
Phase MI oat the workers'compendia,aNdevit easphlely,by chedbing the boon ties apply to your Oman sod,it
nume(s),edesse(a)ami phone oneber(s)along with desk
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town)."A copy olds emdsvit thus hoe ben Washltyr stomped a nudged by the city or town maybe provided to the
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ysac When a hoses owner atcitizen it undoing a Maces or plunk not missed ttrany bosisass or coemmodel moan
as s dog Nome or permit to bans laves sit.)mid pan is NOT remand se coaraphis this edldevit
The case atGusendgdioms would lib to husk you is advance layout complain sod should you hove any questions.
pines de not keitsst to dive w a aiL
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The Commonwealth of Massachusetts
Deputing t of Industrial Accidents
once Invidlpdene
600 Washington stied
Boston,MA 02I 1 I
Tel.f 611727-4900 at 404 or 1-877•MA5S, f g
Revised t t-22-a76 Fax S 617-727--7749
www.msee.0ov/dls
c2 permit(� Ara d ate&
OM*of Cs.e.eeer Adis.Llsei.ess Ryeleie.
HOME REPROVEIfflevir OOWTRACTOR
TYPeVaroaraban
EIRIEMOR
O7ltL
SALT SPRAY SF :
ANDREW WAR RTON
235 GREAT WEST J
SOUTH DEP14IS,M