HomeMy WebLinkAboutBld--20-001879 SHEDS LESS THAN 150 SQ FT SHALL BE o• cc Use Only
PLACED A MINIMUM OF 30 FEET FROM THE „L,D— — S75
�; FRONT LOT LINE AND A MINIMUM OF 6 FEET
0(. - lTtidy FROM THE SIDES AND REAR LOT LINES Amount
Permit expire. 130 days from
issue date
EXPRESS SHED PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS: 2 3 IAA 9-1 0 Q S t /AVtOLIT7A.. f O
ASSESSOR'S INFORMATION:
Map: Parcel: /
OWNER: t tiL --1"/Tv S �-3 frvt e I�►�4 Ltd S'-bSt -77'—G 9 3 2 -
NAME PRESENT ADDRESS TEL. #
CONTRACTOR:
NAME MAILING ADDRESS TEL.#
✓ Plt sidential ❑Commercial Est.Cost of Construction$ >; 7U
Home Improvement Contractor Lie.# Construction Supervisor Lic.#
Workman's Compensation Insurance: (check one)
Yl!am the homeowner El I am the sole proprietor E I have Worker's Compensation Insurance t,j i
Insurance Company Name: Worker's Comp.Policy# 'V
SHED INFORMATION
New )( Size L ! x W / x H rb' ' Corner Lot: Yes No X
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 Cb x III $ x H
*The debris will be disposed of at:
Location of Facility
1 declare under penalties of perjury that the statements herein contained are true and correct to the hest of my knowledge and belief. 1 understand that any false answer(s)
will be just cause for denial or revocation of my license and for prosecution under M.G.L.Ch.261.Section 1.
Applicant's Signature: Date:
Owners Signature(or attachment) Date: /2s1
Approved Bv: / 7?`— Dale: /�Buildina Official(or sign EMAIL iADDRE
Zoning District:
Historical District: 1 Yes No Flood Plain Zone: Yes No
Water Resource Protection District: Within 100 ft.of Wetlands: ***
Yes L. No Yes .. No
***Note:Conservation review required if within 100 t.of Wetlands
9/13
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. The Commonwealth of Massachusetts
MINK 4111111 /,1Department of IndustrialAccidents
_I# 1 Congress Street, Suite 100
Illi�__ ' Boston, MA 02114-2017
IMO 5.•`''V 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): ✓
Address: 23 AA4RIov1- rt S L4iv�,
City/State/Zip:' n Nevvaa. PDK.T Ai A- Phone#: bD 7 '-- 77 4 - &' 3 1--
Are you an employer?Check the appropriate box: Type of project(required):
1.11 I am a employer with employees(full and/or part-time).* 7. New construction
2.0 I am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling
any capacity.[No workers'comp.insurance required.]
3. 1 am a homeowner doingall work myself. t 9. ❑ Demolition
y [No workers'comp. insurance required.]
10 ❑ Building addition
4.0 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.❑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.;
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other
152,§I(4),and we have no employees. [No workers'comp.insurance required.]
*Any applicant that checks box ii I 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 t1 'ns and alt. s of perjury that the information provided above is true and correct.
Signature: Date: c` 2 c/i 9' 1.....
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) EiSe
Well 21
I q� i
- - - I (lot 1 9/U a ft. rear) I
Abuttos s � •t 'CP _ — -
Name �jGon /, �� S, Abettor'
I Name
Lot # sA R l c:.....1.5-76:q
I Lot #
REAR YARD 6A�hk
f this is a dry S K/c L
,orner lot, 7 9....ft. this
vrite in name corner
�f street. I write f
name of
. I a other
ti0.
,� street.
4
• SIDE YARD SIDE YARD •
HOUSE •
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-Ns.:
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: SET BACK •
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•• 3 ft.
I 4
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I
40.
(lot...../•9?'r t.1,'.....ft. frontage)
/ 1444.4,/ NE. RS
\ /
• / (NAME OF STREET)
. -� �-
Information
Supplied by 5 v/ 7 Tv f
(ARK NORTH POINT
•
Information and Instructions G .. :
�t General Lawn chsplor 152 requites ad employ*,to provide waken'compensation he their employees.
Ptususot d this statute.as ce plejw is defined as"...awry parson in the novice of aool m uodet any warned of hire,
morose or inched.oral at wine
As aeplrper le dome sea lodividnsl,porton-drip,arsoeiedon.codpoeados or other legal"salty.or say two or man
olds"Arnpelep sapid is a Jolt atlnpdM,and Intl dleg the legal npwestadva eta deemed employs%or rho
mans of bodge etas ioerideul,portnaship.sseochfion ar odor lepi aultyyy,erg employees. Hoeowat the
owner aladwsWes be.,Wog ad mon rhea three ape nente sod who neida d ndq or the accopeot alto"
dwoUbeg bite olaaat6er who employs persons to de motdameco`oodrmatbs or repair wash on such dwullhsg haw
or as the pour&or building apptetamtet thaws shell not beasune ofsoch employment be donned to be as employer"
AWL duper 13;I23C(6)also states*Wow dale or Meal Useaig spear shell withheld the__nose"sr
remand Os Users or permit to spade a bedseoe or to nosh d huilloge in the esn■toaweeith Aur sy
applied who hr net predated eatapdbl"dame daapMaase with the hoer nose sewtag"rsgirei"
Additional.SAIL agar In,flIC(7)stem Veldts:the�meaor dud lay ponied wbdhdsine shell
entor bee sq contact ha die parhanoce of puha'weak�
acceptable evideaeaalcompliasoe with the iseusa■ee
reguiraussett of this dap*haw been preseatad to the and aodag sudinity"
Appanage •
Phase fill at the waders'compauation affidavit comp) Jy,by checking the bow thee apply to your shades sort;it
oeeaaany,apply sulmoneraeds) vb dhw(a)ad phone nebe(s)slung with dash artftleats(a)at
iaesraaa dratted Liability Caseponies(LLC)ar Limbed Liabaity Patawahip(LLP)with no employee"other tans the
nasmb=orpadtraao,ado oat nquied to any wadies'caspeasedon leaua■oe. Ilse LLC or LLP dose two
employees.a policy is saladd. He advised the tale affidavit may be swbmiued to the Depaeaasut of hands!
Adder*be conflraaMiss dbrntsaaoe cova end Abele are le sips sari dale the dada & Tye affidavit should
be mood to tm city ar town that the appiieades net rho peril or limes is bong seenual,eel the Deposed of
• Wend Addam . Sidi you have soy r nits=ng sling the law as Wyss an repeal to abode a wedeln'
companslin popsy.phew all the Depeedesd at the"amber listed below. Sspien■ed campades saadd ant their
self. ■use Uessse aeaber as he somas 11_
City at Teas Olroide
Phase be see"the the affidavit Is complete and pbrd legibly. The Depattaed has provided i space ado efai M der you to fill out is the Sleet the Office dleradplio■s hes to canon you at the been
Phan be are as flits the nab tb. a
P
permiYdoaes nodes whits will be used r a'chance camber in dabs.as applicant
test most dale nadllple padrUeeass applications Is soy give yeer,ad rely submit as afildtvit iodicadsg current
poUsy it6matios(Ita"seasp)lid wader"lob She Add ams"the appUtaat should writ"al location in
tow "A copy WaftWaftdiet hod bentda llyr"romped arnmdadby the city or loon maybe provided to(city
a
ton*"
applied se pod het a valid alit*V as Ale btr home peens oMa ass& A new sHidevit mint be tilled Out each
yea When a home owner or china Is abashing a Unmet arpaid sal aided to any booboos aeasmand anion
(Le.a dog bees@ or penult to bon Maya ea.)sold pesos is NOT required as compieas this a®dsvit
The Oh sn at Investigations would lib to thud yen is adages der yonrcooperation and should you have any gwslioss,
please de eat hsa ds le give ea a eai.
The Depa.e .it's address`telephone aid Is numb s;
The Commonwealtl of Mauacbuettg
Department of[ndlutili Accidents
oaae err•reeitp*I. .
600 Washington Sheet
Boatoer MA OZI 11
Tel.II 617 72 7-4900 ext 401 or 1-077-MASSAF11
Revised t 1-22•+l6 Fax 1617.727--7749
mammas.
lei6...,;`a.ng
° " TOWN OF YARMOUTH RFCEIvEbJ
1146 ROUTE 28, SOUTH YARMOUTH, MA 02664-4451
Telephone(508)398-2231 Ext. 1292-Fax(508)398-0836 1 I b.G6}}
AN: t 2t)I9
OLD XI 1 G'S HIGHWAY HISTORIC DISTRICT CO4IITTEE
YRKlinUU I N
APPLICATION FOR I OLD KING'S HIGHWAY
CERTIFICATE OF APPROPRIATENESS
hereby
Application is made for issuance of a Certificate of Appropriateness under Section 6 of Chapter 470, Acts of 1973 as
amended,for proposed work as described below&on plans,drawings, photographs, &other supplemental info accompanying this
application. PLEASE SUBMIT 4 copies OF SPEC SHEET(S), ELEVATIONS, PHOTOS, &SUPPLEMENTAL INFORMATION.
Check All Categories That Apply: Indicate type of Building: Commercial Residential
1) Exterior Building Construction: New Building Addition _Alterations Reroof 111 -
Shed Solar Panels Other: -
2) Exterior Painting: Siding Shutters Doors _Trim Other: U� ' 1 [U i u
3) Signs/Billboards: New Sign Change to Existing Sign SOUTH yqCLERKMA
4) Miscellaneous Structures: Fence Wall Flagpole Pool Other:
Please type or print legibly:
Address of proposed work: 23 114-6A(2_1 0, Qf 4 S L 4 le.)6 Map/Lot# /3 Z , 53 q
^vi�A
Owner(s): 5 J aKhrkILe.EAJ T To S Phone#:‘.0q-77(e -69'52i
All applications must be submitted by owner or accompanied by letter from owner approving submittal of application.
Mailing address: 2-, flog e10d5 4.4 4)4 Year built:
Email: $T ICTTIT UJ C a 04,41L e C D bu., Preferred notification method: Phone t/Email
Agent/contractor: Phone#:
Mailing Address:
Email: Preferred notification method: Phone Email
Description of Proposed Work:
A -Pt-A( t ALK"E—i►x 5H-k W ire( p4 AJ,(J 3 Ny
/. XiI
Signed(Owner or agent): 4W — Date:
> Owner/contractor/agent is awa that a permit is required from the Building Department.(Check other departments,also.)
If application is approved,approval is subject to a 10-day appeal period required by the Act.
This certificate is good for one year from approval date or upon date of expiration of Building Permit,whichever date shall be later.
> All new construction will be subject to inspection by OKH.OKH-approved plans MUST be available on-site for framing&final inspections.
—
For Committee use only: Approved Y Approved with a Modifications Denied
Rcvd Date: 8/A3 f j 9 Reason for Denial:
Amount aa o5
Case": t907 A - /
��wy: Signed: ' Ae ' �!/i. IAI
Rcvd by: 411116
�:�jv,=.,Yri
45 Days: IO' —\-` �� . —
Date Signed: 7/23/1 a// lingdgfa "5411 r
1 - 9 - A0 7 6
APPLICATION#:
1
=� MODIFICATIONS TO
CERTIFICATE OFAPPROPRIATENESS
Date: CA 3 12,0 ( 6(
C/A Number: I �1 A-01 C Address: 23 1lk2i 1 e-f t-v-1J Z,
1.
5- ktO ( L k."'Nj-C-TO GA-- FAAD 61-4�P
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c EIVED
4. SEP24alb
TOWN CLERK
SOUTH YARMOUTH, MA
I agree to the above'condlti nd changes to the Certificate of Appropriateness:
Owner/Agent OKH
Signature Signature Z—e-c rk)(A.A.S\
99, 0C
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tif<-.14: S446-77it)4-t
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RECEIVED
SEP 2 4 ZU1J
TOWN CLERK
SOUTH YARMOUTH, MA
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