HomeMy WebLinkAboutBld-20-001657 r.
r �_ �_ ' ce Use I
�,y� SHEDS LESS THAN 150 SQ FT SHALL BE i _
• !�, PLACED A MINIMUM OF 30 FEET FROM THE Pe171,;t, /�5�
'$ �� FRONT LOT LINE AND A MINIMUM OF 6 FEET
d: Iti FROM THE SIDES AND REAR LOT LINES '�'"01n`
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;� � :"ter ,4 Permit expires 180 days from
issue date
EXPRESS SHED PERMIT APPLICATION
TOWN OF YARIvIOUTEI
Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664
"7 l Lc/ J (508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS: f/ bk. WC)U CI-.___..t ...,
ASSESSOR'S INFORMATION:
I
/
I Map: I, ' Parcel:
OWNER: K/�''R L. O /'? 5 i U.i t 7 w/Ldwoo d f 4- 1 77 ` 2 / 6 - 0 ?/(
NAME PRESENT ADDRESS TEL. r
CONTRACTOR: /p,_Q-i g 0 V 322S_ o2 6 73
NAME MAILING ADDRESS TEL.
residential D Commercial Est.Cost of Construction$ k . f
Home Improvement Contractor Lie.# Construction Supervisor Lic.#
Workman's Compensation Insurance: (check one)
'I am the homeowner _ I am the sole proprietor G I have Worker's Compensation Insurance . ,
...;.; ;5.,: o ... : ir
Insurance Company Name: Worker's Comp.Policy# ,
SHED INFORMATION f IJ I;{
New Size L 2 x WI D x H Corner Lot: Yes No D` r :-
Per Town of Yarmouth ZoithiR 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 WY x H
*The debris will be disposed of at:
Location of Facility
I declare wider penalties of perjury that the statements nt con' med are true and correct to the best duty knowledge and belief. I understand that any false answertsl
will be just cause for denial or revocation of my li• se and fc rosecutio n M.GJ...Ch.268.Section 1.
Applicant's Signature:_ Date:
Owners Signature 1:Iu1thu1thh1
0 ---_.. --.. _ Date: �J '�
Building OtTici or d' —..._....._......._._........ ..__._. ....._
ice) EMAIL ADDRE ---
Zoning District:
Historical District: ...I Yes No Flood Plain Zone: Yes No
Water Resource Protection District: Within 100 ft.of Wetlands: *`''*
il Yes L.I No . Yes No
*:K*Note:Conservation review required if within 100 ft.of Wetlands
9/13
r
. The Commonwealth of Massachusetts
11-*W'l11►== /. Department of Industrial Accidents
=NEL= 1 Congress Street, Suite 100
' E_ ,' Boston, MA 02114-2017
• u SY.y4. 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): f� L ifeci h'$i qj/i
Address: 7 IA L. 1 wO 0I7 Pig-j74
City/State/Zip: (Li. //-pj.Li /_ 2i 3 Phone#: 7?9-2(6 -698 •
Are you an employer?Checif'the appropriate box: Type of project(required): ,
1.0 I am a employer with employees(full and/or part-time).* 7.63 New construction
2.0 I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling
any capacity.[No workers'comp.insurance required.]
9. ❑Demolition
3. am a homeowner doing all work myself. [No workers'comp.insurance required.]t
`/ 10 0 Building addition
4.0 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. 12.0 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.❑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 Squired under MGL c. 152, §25A is a criminal violation punishable by a fine up to$1,500.00
and/or one-year impriso - t, 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 v. ',
spy.py of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verifi'�'on r'
I do hereby "%fer the pains and penalties of perjury that the information provided above is true and correct.
Signature• Date:
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#:
f
4 PLOT PLAN
I " $
FOR LOT #
Indicate location of garage or accessory building
Additions with dashed lines
Sewerage disposal (cesspool) ED
Well. 2r
I
I (lot ft. rear)
_
1 _
1 'fl'
Abuttor's
Name wi I Abettor'
Lot M 6 I Name
I Lot s
f this is a 2 E.--iREAR YARD
:orner lot, ft. If this
'rite in name ' comer
'fit• writef
,� name of
v$°i I a other
,1) street.
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. 4
: SIDE YARD
SIDE YARD •
HOUSE •
ele ! (vi
. � .
: SET BACK :
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ft. •
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(lot..y...-f.... .•...ft. f ontage)
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(NAME OF STREET)
Information
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(ARK NORTH POINT