HomeMy WebLinkAboutbld-20-2554 y SHEDS LESS THAN 150 SQ FT SHALL BE Office Use Only
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�^S �- THE PLACED A MINIMUM OF 30 FEET FROM ,Pennit'i
gj 1 FRONT LOT LINE AND A MINIMUM OF 6 FEET
pig l 1ti FROM THE SIDES AND REAR LOT LINES Amount 3S
Permit expires ISO days from
issue date
IRECE V DH
EXPRESS SHED PERMIT APPLICO I , N
TOWN OF YARMOUTH i NOV 01 2019
Yarmouth Building Department4 4
1146 Route 28 13'l `s
South Yarmouth, MA 02664
(508) 398-2231 Ext
1261 �J
CONSTRUCTION ADDRESS: / i9 G jj.'e51-ern �d C�r'7A1 yfrinlmil
ASSESSOR'S INFORMATION:
,`- Map: Parcel:
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OWNER: /�ei�1z�SiN�o /4,9 Crrol e ✓i1 R Sod g,�S'SIay
NAry ' PRESET IT ADDRESS TEL. II
CONTRACTOR:
NAME MAILING ADDRESS TEL.8
O'O
Residential ❑Commercial Est.Cost of Construction$ t f cerO
Home Improvement Contractor Lic.# Construction Supervisor Lic.
Workman's Compensation Insurance: (check one)
X1 am the homeowner CI I am the sole proprietor C: I have Worker's Compensation Insurance
Insurance Company Name; Worker's Comp.Policy#
SHED INFORMATION
New V Size L x by / x H Corner Lot: Yes No 1/
Per Town of Yarmouth Zoning Bv>-Law Sec 203.5 E:
Side and rear setbacks Pr 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 I'l'. x H
*The debris will he disposed of at: 7&IA!/I /'r/Y1 O v l 4 �U yyt A
Loca ion of Facility Q
I declare under penalties of per that the statements herein contained are true and correct to the best of my knowledge and belief. I understand that any false answerls)
will be just cause for denial or rev t ion of y lice se and for . see tion under M.G.L.C:h.263.Section 1.
Applicant's Signature: _ Date: //"/ ar)/ 7
•
Owners Signature(or attachment) Date: l /2Cl//
Approved 13y: - Date: _ "`!.
E3 _._.....� _
building i or deli lee) EM ADDRESS:
Zoning District: _
Historical District: ' Yes No Flood Plain Zone: Yes 1 No
Water Resource Protection District: Within 100 ft.of Wetlands:
Yes No i Yes No
** Note: Conservation review required if within 100 II.of Wetlands
9/L
The Commonwealth of Massachusetts
I a /, Department of Industrial Accidents
fl tail- 1 Congress Street, Suite 100
_F1_ Boston, MA 02114-2017
U. 4' i www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
c....,_-/� /)�
Name (Business/Organization/Individual): </^1 /0i7_^ N J 5,h'1)
Address: 1'1 �-/ r Alf Sc('vl RdV
City/State/Zip:�h11P l AIM��`� MAI Phone#: Q 1" az Ss-,S-/ 6 y
Are you an employer?Check the appropriate box: Type of project(required):
1.0 I am a employer with employees(full and/or part-time).* 7. E New construction
2.0 I am a sole proprietor or partnership and have no employees working for me in 8. El Remodeling
any capacity. [No workers'comp. insurance required.]
3. I am 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.Q Electrical repairs or additions
proprietors with no employees. 12.0 Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑ROOF repairs
These sub-contractors have employees and have workers'comp.insurance.t
6.E We are a corporation and its officers have exercised their right of exemption per MGL c.
14.❑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 certify/nder th`,ins and permit' s of erjury that the information provided above is true and correct.
����
Signature: ��%�1i/,'►. Date: /��--/- A/
Phone#: - c S0= /c i
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#:
1 , • •
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of PLOT PLAN
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FOR LOT #
Indicate location of garage or accessory building
Additions with dashed lines
Sewerage disposal (Cesspool) ED
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Abuttor's
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SIDE YARD
HOUSE SIDE YARD :
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Information
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(ARK NORTH POINT