HomeMy WebLinkAboutBld-20-00598 SHEDS LESS THAN 150 SQ FT SHALL BE Office Use Only
PYll PLACED A MINIMUM OF 30 FEET FROM THE
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'`k= FRONT LOT LINE AND A MINIMUM OF 6 FEET
, FROM THE SIDES AND REAR LOT LINES Amount `S�
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EXPRESS SHED PERMIT APP.LICATI 1 AUG 01 2019
TOWN OF YARMOUTI-I
Yarmouth Building Department Buell RENT
1146 Route 28 By:
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS: C.9 1 + 1 1 �-(,.`y�.�l1\ `. `5 . 0% L 61 '- I�, O z„/^L`.�`J
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ASSESSOR'S INFORMATION:
Map: Parcel:
OWNER: "c r S tC' g il I `r` '' `c(.: <:`' ; ffi t . e C 7 :26- �j.�/3
NAME dI PRESENT ADDRESS TEL. '-'
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CONTRACTOR: t l 6 l Y '(r `` t t_.,, 'Z..t" C..nC'. I 1 'c7" * ` �.....11;-_, ‘f"C.. I
NAME MAILING ADDRESS 1 TEL.it
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t residential ❑Commercial Est.Cost of Construction$ 7, Oe
Home Improvement Contractor Lie.# Construction Supervisor Lie.#
Workman's...ompensation Insurance: (check one)
f'am the homeowner I am the sole proprietor C I have Worker's Compensation Insurance
Insurance Company Name: Worker's Comp.Policy#
SHED INFORMATION
New Size L 6? x W # i x H c,:.. Corner Lot: Yes No- y
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:
Location of Facility
I declare wider penalties of perjury that the statements herein contained are true and correct to the best of ow knowledge and belief. I understand that any false answert s i
will be just cause for denial or revocation of nr;lie- e and for prosecution under'it.G.L.Ch.263.Section 1.
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Applicant's S. ature _.,e,8'IM - Date: /) j - i
// ' '
Owner ,ignature or aura am nt 4 r c/
t Date: --�� � ' �-' •
Approved By:_-- i Date _ �. '
I3u4010. fici � EMAIL ADDRESS:
Zoning District:
Historical District: 1 Yes i No Flood Plain Zone: Yes No
Water Resource Protection District: Within IUU ft.of Wetlands:''A"*
Yes No ; Yes No
'`**Note: Conservation review required if within 100 i1.of Wetlands
91
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. The Commonwealth of Massachusetts
I _'u,, -r Department of Industrial Accidents
W- 1 Congress Street, Suite 100
7=_ ` Boston, MA 02114-2017
sy°'�� 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: V
City/State/Zip: Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
1.❑I am a employer with employees(full and/or part-time).* 7. Z; ew construction
2.❑I am a sole proprietor or partnership and have no employees working for me in 8. III Remodeling
any capacity.[No workers'comp.insurance required.]
3 am a homeowner doingall work myself. t 9. ❑ Demolition
y [No workers'comp.insurance required.]
10 ❑ 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 11.0 Electrical repairs or additions
proprietors with no employees.
12.EI Plumbing repairs or additions
5.0 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.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 14.0 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 under the pains and penalties of perjury that the information provided above is true and correct.
Signature: i, ;' a \: f
( ;Date: / ) ):j
Phone#: r
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
. ►6. ,
FOR LOT #
Indicate location of garage or accessory building
Additions with dashed lines
Sewerage disposal (cesspool) e,
Well Is
I I
- - - _ I (lot ft rear, I
Abuttar's Ct. _
Name IAbettor'
Lot # I Name
I Lot #
f this is a REAR YARD
garner lot, ft. If this
trite in name I corner
if street. I write i
,� name of
a I a other
'
b ,� street.
4
4
: SIDE YARD
: •
HOUSE •
T= �
SIDE YARD
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. SET BACK :
-....! s �a -..•sue... •
4 e�.
�+ • ft.
t" v I J '�1 -;i
IT cl
aq
(lot ft. frontage)
/ r} 1Ie . r
\ / (NAME OF STREET)
Information
Supplied by
IARK NORTH POINT