HomeMy WebLinkAboutBld-20-002435 --.1-,
SHEDS LESS THAN 150 SQ FT SHALL BE -.Office Use Only
� A i\.,
PLACED A MINIMUM OF 30 FEET FROM THE
Sti Penuit'f
FRONT LOT LINE AND A MINIMUM OF 6 FEET
0, - � /1tiy.Y FROM THE SIDES AND REAR LOT LINES Amount
"* Permit expires 180 days from
°*� p
-�:. " issue date
e U)-20- CO23435 I V
ED
EXPRESS SHED PERMIT ATOWN .EICATIr TON OF YARMOUTH tCT 28 2O1
Yarmouth Building Department i
1146 Route 28 ' T
South Yarmouth, MA 02664 I:uii%tl_. _
(508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS: l/V COI l. yn ikvaLP-(/>
ASSESSOR'S INFORMATION:
1,� Map: ^� �'4. Parcel: �
OWNER: �CL� I`ek. �� 39 ! f Sl', l s e 70arop-wui
s.00
NAME i 1 PRESENT ADDRESS �T�EL. #
CONTRACTOR: i, ( �J C'Q ► I { N t 6 C rC'10 pem.a /
r � I yar &d a . ( 6-
NAME —�� MAILING ADDRESS TEL.it
ov
`residential 0 Commercial `� # O "l Est.Cost of Construction$ /�IE0 0 —
Home Improvement Contractor Lie.Or' J t 360 6 Construction Supervisor Lie. Ni a 7
Workman's Compensation Insurance: (check one)
0 I am the homeowner ✓—Q am the sole proprietor f_ 1 have Worker's Compensation Insurance
Insurance Company Name: Worker's Comp.Policy#
SHED INFORMATION
/ ; t
New () Size L fj x YV S x H 'c Corner Lot: Yes No 1/
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 IF x H
*The debris will be disposed of at: (k.2' `
Location of Facility
•
I 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 answers;
will be just cause for denial or revocation of my license an rosecudo nd- M.G.L.Ch.268.Section 1. Q _
Applicant's Signature:' _._ Date: / 0 v� \ �,1
Owners Signature(or attachment) Date:------....10-D el_
Approved By:. i - �' Date: G — ��7
I3uild• f designee) Eh DRESS:
Zoning District:
Historical District: Yes ri No Flood Plain Zone: Yes No
Water Resource Protection District: Within 100 it.of Wetlands:* ,*
Yes No ' Yes L. No
***Note: Conservation review required if within 100;0..of Wetlands
9113
r
The Commonwealth of Massachusetts
Department of Industrial Accidents
_9EJe- 1 Congress Street, Suite 100
4kw : 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): (2)-(1) y Y
Address: ( 6' eoed'1ts loaA4
City/State/Zip: Q // [li - (V6 p 1 Phone#: . t-D66
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.KNew construction
IQ am a sole proprietor or partnership and have no employees working for me in 8. ❑ 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.]
4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will
10 ❑ 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
5.0 lam 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,§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.
lContractors 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 cert. under the pains enaltie erjury that the information provided above is true and correct.
Sianatur "F-
Date:
Phone#: ,- t .FS)'—" ` ��
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#:
f
y •
of PLOT PLAN
FOR LOT #
Indicate location of garage or accessory building
Additions with dashed lines
Sewerage disposal. (cesspool)
Well Cia
I I
I (10t..1.3.gt 4. ft. rear) I
- - - -
Abuttor's <> _ — —"
Lot # I if 6 Abuttar'
Name
Name
V Lot #
'I this a REAR YARD f t
:arner lot, ft. 6 `7� . ,. If this
write in name rner
sheet. f `
I
,� write i,
f M/ name of
a I a other
ti ,� street.
: SIDE YARD •
SIDE YARD •
HOUSE: <1-- — —it- 0 0----- U0 i
.
11 . .
.
SET BACK ��
4I ft .
A
I Q
(lot......... .P.I....ft. frontage)
1
\ tA)s.e)e/
/ (NAME OF STREET)
Information
Supplied by i - -- y (I-
!ARK NORTH POINT
Jam° W. . deg/.../X
Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR,
TYPE:Individual
Ecoiration
09/24/2020
BRUCE MILLS(sl1-1
t7
Ima
BRUCE P.MILLB('4
16 CROOKED POT R'
HYANNIS,MA 026 '�` -: '0' Undersecretary
Commonwealth-of Massachusetts '
[®J/ Division of Professional Licensure-
Board of Building Regulations and Standards
Constr, r tlp,rvisor
•
CS-078687 -, 'i ppires: 05/29/2020
Air
BRUCE P MILES
16 CROOKEDONP
HYANNIS MA s2 1 , 5•�
. .
Commissioner