HomeMy WebLinkAboutBLD-20-488 J y Office Use Oniy
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`" s*ut,"" Permit expires 130 days from
�/ I� �j issue date
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EXPRESS SHED PERMIT APPLICATION 3 b-E
TOWN OF YARMOUTH
Yarmouth Building Department lD
1146 Route 28
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS: Li 9 C-/J 2o-0 5LG
ASSESSOR'S INFORMATION:
Map: Parcel:
OWNER: /Z$ —EAc.) '7? a PO L) 56 8'-.2 S-5
NAME PRESENT A DRESS TEL. r
CONTRACTOR:
NAtvIE MAILING ADDRESS TEL.
*Residential 0 Commercial Est Cost of Construction$ 4 ri iero
Home Improvement Contractor Lie.R Construction Supervisor Lis.R
Workman's Compensation Insurance: (check one)
I am the homeowner . I am the sole proprietor G I have Worker's Compensation Insurance
Insurance Company Name: Worker's Comp.Policy#
SHED INFORMATION
COI a4
New )t Size L x x H Corner Lot: Yes No X
Per Town of Yarmouth Zoning Bp-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 I-F x H
'The debris will be disposed of at:
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 answer(s)
will be just cause for denial or revocation of my license and for prosecution under M.G.L.Ch.265.Section 1.
Applicant's Signature: Date:
::: r
ure attachment) Date:�Z /
� 1✓/
Date: —— •CA,•-�-C`
Building Official(or d ignce) 9A[L ADDRESS:
Zoning District:
Historical District: ei Yes No Flood Plain Zone: Yes No
Water Resource Protection District: Within 100 ft.of Wetlands:.;:,
Yes - No f.1 Yes No
$* Note: Conservation review required if within 100 h.of Wetlands
9%13
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The Commonwealth of Massachusetts
, ........s Department of Industrial Accidents
_9EI�d"rl_ 1 Congress Street,Suite 100
r
E'E:f= Boston, MA 02114-2017
, www.rnass.gov/clia
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: Li 9 [. rze,,).5f__ ,A.)� /
City/State/Zip: W . PI- o c)rLi__ Phone#: s o-% "g1 — L f( 5)
Are you an employer?Check t e appropriate box: Type of project(required):
1.0 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
capacity.[No workers'comp.insurance required.]
3. I am a homeowner doing all work myself. [No workers'comp. insurance required.]t 9. ❑ Demolition
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.❑ Electrical repairs or additions
proprietors with no employees.
12.❑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.❑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#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 d• the pal. a..a p ti�/, perjury that the information provided above is true and correct.
Signature: r7/ �� Date. SDI' -P- L-/,57
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#:
_ . ..adiiii
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•
PLOT PLAN
. r s
FOR LOT #
Indicate location of garage or accessory building
Additions with dashed lines
Sewerage disposal (cesspool)
Well igi
I
I
a I
(Lot ft. rear)
Abutter's 0* —
Name I Abutter'
Lot # I Name
I Lot #
:f this is a REAR YAR
:arner lot, - h... If this
vrite in name ft. corner
�f street.
�--
write i,
17 r.P09 \ �� I 1.- e" k� o, name of
.y� �r / v. `v° street.
SIDE YARD SIDE YARD
• HOUSE •
. •
•
•
• I•
. I •
.
. SET BACK •
•
ft
•
4
1
1
1
a
(jOt '11 ft. frontage)
/ eteoVS ,,,,f
/ (NAME OF STREET)
Information
Supplied by
LARK NORTH POINT
Information and Instructions
to wears'comparado.her their eeopbs,eee.
General Laws chapter is2 tegesitme employ**to the moire of another under soy cared(White,
tbie stride,an aglow le'h as"—sway paw
express at implied,oral or w itta."
As rssplepr is defined as"se iodic bisk psetaasldA sasoaled•4 co'paadoaat otet legal ee iIy.or any two
or the
sod fed f� of a deceased employed&
Of the Asa budge
aas+sld her•1M id hscarsoaistbss at odor legal edit%snt Liylei oy suer Iftnrees the
maim alt bmetw doshsdleidoat.�!► md�ehsneidsm t�or�occupies ads
crews eta dwr111si bore having eat°ton ties there system* roaNeaedaa or mar weak as such d+sstimi house
dwelling bosses amide'budd who room� of such employments be damned to be as "
or o><des pweda bmiWf:t�
hiGL
chalks 132,125C(6)also Males dye"every Mate ae Meal!Wades s y seer withheld the bosom r
•halms r to asatrsest belMbp bs the 5s uswiiith dyer�
applied e.evrel et a has net period � edam se mumbr•i will lbs Irsrii a rairegs(rewired*
abs sae net produced aeeept>tW he political rWasa shell
, ,MOL charmOmdyer perib i err ce aphis�usW her de commensealth wryO with the
east ION my cooker loserince
otdds eWeir have beat promutol is the eaakaatW w —1ltl►.
Apple.els •
dadavit eoaepistel�by dish die bens that apply to your ail.ado @ sad,it
Please Oltat the ter ems).sdiess(ee)and p�a�e6a)s with disk )of
n.aaaay,applyLimit et LWO Liability laaaeldp•(�)all me employer met than tho
ins ssa Limited Lis orar required
d ( wosens'compe•edb.laasaaa. If se LLC a LL1 does have
an or emgissd to any' ari�agsi:ed, Be advised th.tthis'Merit may be submitted to the terse of Weida'
ampler." atinarII cove/see. Ake be as.le sip dat
aid e the alWavit Ilse'Mavis should
be mooted se the sky ea lows diet the appitad.s bade pwmtt at dome is bet g aR..erd,met tee Deponent
of
• IadeekW Axidaeea 3beeld re have soy gessbss repulleg die kw or ire are respired is abode r worker'
compeo rdoe may,please ail die Dep osper d the umber Mod balm SelEissaed campaniles would Bair their
aiWimare se beam safer am tie sossopl.s Beer
City r Taws Gabble
Please be cam tb.t the e®dsvit is complete and pistol kgibly. The amass hasprovideda specs at the bombed
ado affidavit dr as to III vet is the swat the Mks oflavesdptles lees as coated Yam eepolees the
Mee be sons MI is 'somber whle
i wi>t be rid as a referees,somber. fa sddtdos,a appYd tbst mod
ea
arid*permielicesse appliadom d any gives year,meiaaly submit eos.mdatit iaadescaQmmt
(if )sea*mkt lab SW Address"the.piker should mile"al leeadoes era (city as
tows*"A copy oldie salts*that hes bra add*ataatp.d atn..lmdby the city cram maybe provided is the
app_e..t r padre a mild albeit is as de for Mere lets as User's. A asw a®dav*meat be Idled out each
yam Vibes a Ibises se psrmit est Ward to say busker or cosesseschg venture
(tee: dog g a ow peewit to bass leaves said peon is►`OT req.itmd es coupler this agldevitt i
The Ogles of Iaveadpdoes would lib r thud roe is adman darer r coopaatleo mil should you have any question..
plows de not heelers to give us a call.
[fed Ospsrmseet'e address t lephme aei he dumbest
The Commonwealth of Massachusetts
Dees ttmast of industrial Accidents
Mks elfavestrpdsu
600 Wiishingles Street
Boston,MA 02111
Tel.11617-727-4900 est 406 or 1-$77-MA93AF13
Fax F 617-721-7149
Revised t1-22a16 ynwarmaa.gar/die •
TOWN OF YARMOUTH
HEALTH DEPARTMENT
PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET
To be completed by Applicant:
Building Site Location: I.( Cl 42 0 z1 SG 1'"49
Proposed Improvement: `-I e 4
Applicant: E✓2A,L.)ebr,21) A_A)7 Z Tel. No.: $-a5/-1- j�
Address: tj e.2024,0E_ Date Filed: 7/,00i9
**lfyou would like e-mail notification of sign off please provide e-mail address:
Owner Name:
Owner Address: Owner Tel. No.:
RESIDENTIAL AND/OR COMMERCIAL BUILDING
HEALTH DEPARTMENT: Determines Compliance to State and Town Regulations; i.e., Requirements
For Septage Disposal and other Public Health Activities.
Please submit three (3) copies of plans, to include:
(1.) Site Plan showing existing buildings, water line location,
and septic system location;
(2.) Floor plan labeling ALL rooms within building
(all existing and proposed) —
Note:Floor plans not required for decks,sheds, windows, roofing;
(3.) If necessary, Title 5 application signed by licensed installer
with fee.
REVIEWED BY: fr)/ DATE: 7 1 ci
PLEASE NOTE
COMMENTS/CONDITIONS:
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TOP OF FOUNDATION 20 FT. MINIMUM FROM CELLAR
ELEV. .. 100.00 10 FT. MINIMUM 10 FT. MINIMUM FROM SLAB OR CRAWL SPACE
(ASSUMED) --\\A3
CONCRETE
COVERS
4" SCHEDULE 40 PVC PIPE
MIN. PITCH 1/8" PER FT.
4" CAST IRON PIPE 6 rX' ij
(OR EQUAL) MINIMUM
PITCH 1/4" PER FT.
, 4owuNE A YELEV. ' \ _
MIN. LEV. *1l
ELEv. - _'��1 `/ ` -1 G„1,5
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. CBA E EllV. : `1�;, EV,
4 DISTRIBUTION
LI JID OUTLET BOX
DEFTti 4 RET EEINCHES (TO BE PLACED ON FIRM BASE) TO BE WATER TESTED
6 FEET 24 INCHES 1500�+ GALL IF MORE THAN ONE OUTLE
7 FEET 29 INCHES SEPTIC "TANK (TO BE PLACED ON FIRM. BA
3/4" TO 1 1/2"
DOUBLE WASHED
FREE OF FINES
SEWAGE DISPOSAL SYSTEM PROFILE
NOT TO SCALE
n 99.0
RECElykD
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JUL� 2 2019 y °
\rG ` HEALTH DEPT, , •
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