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Home My WebLink AboutBld-20-00329 •pT•Y,„, Office Use Only PermitN Amounts r�Cc-� Permit expires 180 days from issue date gLb— a?� EXPRESS SHED PERMIT APPLICAT TOWN OF YARMOUTH E C E I V E D Yarmouth Building Department 1146 Route 28 JUL 19 2019 South Yarmouth,MA 02664 I , (508)398-2231 Ext. 1261 B U_HdTMWR ENT By CONSTRUCTION ADDRESS: 43 f on(OL, ant ASSESSOR'S INFORMATION: iii Map: 7 Parcel: 22. OWNER: �lrn hr1 .Llr{ul h,�m y5 Iir}�l Ne-lt• ��l D i 7caQ 1-Pi• 0.3� NAME T- PI ENT ADDRESS � TEL. N CONTRACTOR: ! 1lt I2lbly rirrail s a.sq CkxtnAfilyTd)j-4ô . ma SOB J 3Da8 0 NAME MA MATING ADDRES TEL.N II/Residential 0 Commercial Est.Cost of Construction S '`) S(I e Rome Improvement Contractor Liic.fl I 3.7q,35 Construction Supervisor Lin it 1138(,05 Workman's Compensation Insurance: (check one) 0 I am the homeowner . I am the sole proprietor I have Worker's Compensation Insurance Insurance Company Name: -cLLi / Worker's Comp.PolicyH SHED INFORMATION New ✓ Size L 12 x W e) x H. I I '7 9 Z" Corner Lot:Yes No ✓ Per Town of Yarmouth Zonine BwLaw Sec 203.S 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 W x r `�u l *The debris will be disposed of at: S T J 0 �J 1 v �- v Location of Facility l 1 declare under 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 answa(s) will be just cause for denial or ocation o li and for prosecution under M.G.L.Ch.268 Section 1. �y Applicant's Signature: • 7f 04' GR--) Date: /// 7/1 / 7 Owners Signature(or attachment) o Date:Approved By: Date: / //�� /5 Build' '• .!(or ignee) IL ADDRESS: Zoning District: Historical District: '1 Yes No Flood Plain Zone: Yes No Water Resource Protection District: Within 100 ft.of Wetlands:••s Yes I No Yes I No sseNote:Conservation review required if within 100 ft.of Wetlands 9/13 The Commonwealth of Massachusetts ► __- __E! Department of Industrial Accidents ®__ 5 1 Congress Street,Suite 100 Boston, MA 02114-2017 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): Mr 6ra4h ?os-;' s C3earn Gorj�/yr�iy Address: asq Quail Anne. � � �'�`�d City/State/Zip: Harwich fe)(11 II Phone#: 508 4130 028U0 Are you an employer?Check the appropriate box: Type of project(required): 1.El I am a employer with e30) employees(full and/or part-time).* 7. [ New construction 2.01 am a sole proprietor or partnership and have no employees working for Meiji,, rT , 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 9,. 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]' ❑Demolition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property I will 10 El Building addition 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.El Roof repairs These sub-contractors have employees and have workers'comp.insurance.: 6.0 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: NNi Nampshwe Emplobers jnsnra ni t' (ornY1nti Policy#or Self-ins. Lic. #:FCC-&CIO-LOINS -Qt AA Expiration Date: V -Ir, A, aO 1O Job Site Address: 93 /�max. j„f ne City/State/Zip: W?armo(}th, mil 02o ) 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 u r he pains an e ' s o erjury t ' e information provided above ' tru and correct Signature: Date: - I la iq 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#: PLOT PLAN FOR LOT # Indicate location of garage or accessory building Additions with dashed lines S 6-0 Sewerage disposal (cesspool) ® pa Ti C� welly �Z I -- - - _ I (lot ft. rear) Q - -- Abuttor's ' Name 8l r • Abutter' l' Name /� i Lot # :f this a REAR YARD I �fl/� corner lot, ft. If this trite in name 1 corner • 't write ii name of 43 is other ti street. . • : SIDE YARD • HOME SIDE YARD • • �__ — r • a_____ �,� . . . . . • . . I . I . . SET SACK • • . ft . i I I (lot ft. frontage) C CLOE / (NAME OF STREET) Information / • Supplied by !ARK NORTH POINT