HomeMy WebLinkAboutBld-20-001000 SHEDS LESS THAN 150 SQ FT SHALL BE office Use Only
PLACED A MINIMUM OF 30 FEET FROM THE Pcnnitti
( �CF FRONT LOT LINE AND A MINIMUM OF 6 FEET 2
d! Itia FROM THE SIDES AND REAR LOT LINES Amount vb�'
�� MATTACt! [36�
�';� •„'"� Permit expires ISO days from
issue date
,i3U-a u- I DC) yRECEIVED
EXPRESS SHED PERMIT APP.LICATI T~�
TOWN OF YARMOUTH AUG 22 2019
Yarmouth Building Department .._
1146 Route 28
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261'-CONSTRUCTION ADDRESS: jt 7 ���,�J�/ �1] . �� .ST At'itiz2a77,/ 00 U 73
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ASSESSOR'S INFORMATION:
Map: Parcel:
WNLR:, )/1J X 64Ae/(,,(/L rn) S'[r u' d CwV /4 r /..�Z �'/ 3c —C���7
NAME -'PRESSEi`I'1�'`ADDRESS' /,y O�
TEL.
CONTRACTOR
J°VACS A(�.�tre `S /N CJ 1 C� n� „ , 15• Lkv • a%O 0
E 'IAILUNG ADDRESS TEL.C o0
Att
f�Residential 0 Commercial Q� Est.Cost of Construction$
31 \�O
/'Rome Improvement Contractor Lie.r t3a 1�� Construction Supervisor Lie.it C_ ( 'u �
Workman's Compensation Insurance: (check one)
-1 1 am the homeowner _ I am the sole proprietor [-live Worker's Compensation Insurance
Insurance Company Name: \ts. \kQk f411ct Eylvlo \INS. Worker's Comp.Policy#c Apt LOVICA
SHED INFORMATION
/ rr
New )! Size L/02 x W / x H ,� Corner Lot: Yes No
Per Town of Yarmouth Zonirz Br-Law Sec 203.5 E:
Side and rear setbacks for acce.ssony buildings less than 150 square,feet and single stogy, shall be 6 feet in all districts, but
in no case built closer than 12 feet to any other building.
Replace existing* / Size L 1e2 x 14% g x H 9 f� /,
*The debris will be disposed of at:CJ'cve- 7) 36 .C?/f/ ` rs/ In `L y'r,AJQ/141 7/ o �.7 3
•
Location of acuity
t 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 rpocation of liven n for ossee n under M.G.l..Clh.268,Section I.
Applicant's Signature: /7�_ Date: ki2r2/,
Owners Signature(or attachment) Date:
Approved By: Date:
$
Buildina Official(or designee) EMAIL ADDRESS:
Zoning District:
Historical District: Yes No Flood Plain Zone: Yes No
Water Resource Protection District: Within 100 it.of Wetlands:* *
Li Yes Li No Yes Li No
• ***Note: Conservation review required if within l00 ft.of Wetlands
9/li
amm e,ligV e Sma;/, comer
' The Commonwealth of Massachusetts
I =*_' _ Department of Industrial Accidents
1 Congress Street, Suite 100
= N ' Boston, MA 02114-2017
\i='s'' 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): M,C G,1rok- TiDIA ' ---- €C.Vri C.0 ryy�X--4- O y�
Address: 2 3R QoeJz. A -w Q, a o `_
City/State/Zip: \-\(}, \ch 1 'NVP Oa(04 Phone#: CDS.• • a%P
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. 0 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.]
3.0 I am a homeowner doing all work myself. [No workers'comp. insurance required.]t 9. ❑Demolition
10 ❑ Building addition
4.0 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.
12.0 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.1
6.❑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: New Ou'Yi 11
l\,i v e. 6-v \0 trs \numxc.,L Qütnpcn3
Policy#or Self-ins.Lic.#:CT.—(QED--4660151 — a o gPc Expiration Date: ('0 ki) S , aoa�
Job Site Address: /7 4:57s7r7 ii6) e) City/State/Zip: GI) �K�-Af—pi;g'i C> Z,7 3
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expirati6n 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 certiff nder the
ains and penalties of,perjury that the information provided above is true and correct.
Sianature: (`_,__ i�_ ki
' �'/�'/ Date: F 2,9 J'
Phone#: G'/7- �O/,2 9
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#:
•
•
e PLOT PLAN
FOR LOT #
Indicate location of garage or accessory building
Additions with dashed lines
Sewerage disposal (cesspool) ED
Well 21
I
I
I (lot ft. rear) J
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Abuttar'
Name A•uttor'
Lot # I � a
#
:f this a REAR YARD
'orner . ft. . this
vrite name , ,
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13 : 4
• SIDE YARD id. SID YA D
HOUSE •
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SET BACK • '
.
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a.+ ft
I J.1
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a
(lot ft. frontage)
R---oce . 17
(NAME OF STREET)
Information
Supplied by
PARK NORTH POINT
Information and Instructions ..
mandustesGeneral Lawn chapter 132 sequins sU employee to provide warn'comp.asdus Sir their.Opl eyesa '
Pursuant to this sister.as apll ymir is Mind as"....very ponce to the novice of mother midst sq caahaet entice
express or implied,octal or nine."
As arptsye►is dared,."at individual.pate.ahip►asonsiedoo.cusp-.dos or other lapi any.as say two or mass
of the hasping espied is One edaprieer and Inhales the kpi raprasetoeivea ale dessood swim or the
maim es berm oleo indMdod.pattsswYR aroaisM1n or other Ispl a dtA employing roployoss. Bowan the
awes otsdwelling he..beving not snore thee three siostmwrt aedwhe resides hook or the ossmpor of he
dwelling bow easiest who employe poor is de meLesesse.coasraedoe armak work as sash dwell'''.house
or on the pounds or buddies apparuraset than shay sot because alsuch.mpiuymrat be deseesd to be.a eatpMyet•
MOL chaps 132.121CO)she rinses that"every two at Mal Wert spec,sad withheld Its homes er
r.eewel'Wheless or permit to spurs*s baker sr to aeastrest hvelmegs he the eaaaaaaweaph Si,sq
spplita■t who he setpredsssd sas.ptshlo midgets.lampaaase with the hmonaae avers.mina"
Additions*.MOIL.chapel 13l.)257)states"Pries the aoaasoamaddi not sq ditto poiltkal subdivision she/
ages We re cosine At the pythoness airline work uedl sseapeebir.videeee elcoaptieese with the iosuasao
r.gsineereeaold*chapter hen ben peewelmd to thecoeeeaetre authority."
Appian •
Pleas Si out the wears'ampeasetre amden oarpisrly,by shoddy'the biers that apply to your sieerdoe sod,it
neoeeaay,supply sulmo■nsom(s)aeon(.)`dkw.(s)aed phone aoba(s)along with their cerdf aE(a)at
ineusasoa Limed LtebShyCoormi s(LLC)or[Amid liability lutaahipe(LLP)with no ospleyg other the the
members arpeseeere`are eat ageied eo assy swims'caetp. etdaa loom.es. It as LLC or UP dose have
employes',apulley is repsitsd. Be advised that th u a0lievit may be sbmioad us the Depatessa of ItdeeUW
Aceithtgp he cu.timatiae of Lrneeeoe oovrrsen Abe be ass to alp and dale he amdevit. The amdavit shard
be atmsae1ts do city or town thee the appiiad.a Annie point or thew is big sespweed,let he Daperons■t ed
• Iader delAosid es. MOW yea have eg9eools■n npnleg that lawae Ify.s ass regeiel is abler a werhree'
corps■ vie pollss phase eau the Daperoeset at th member listed berm senesced cerelve■iee should air their
sell hoorre Weave webw as the sonee ate Par
City sr Toms Deblois
Pines be ere the the adldevit is complete and primed legibly. The D.prmnat has plevidol i specs at the bon
otthe rmivit he yes to Mt ova is the event the Oaks ottavodperos he to canon you regadtsg the appaeuet
Please be see is di is the penancsese number which will be said as s mheeaoo atsnbs.. Is additioq a sppWact
that..'submit meld*prrmillaces=appaadoea is say lira year,need say submit or salmis Wong cou t
policy hammiest Of neseaery)wit under lob Me Maser the appaeaet should write".a radon is (city or
town)."A copy if she Widen the has berm abbey etaoped arasekMbythe city or town may be provider the
applieamt espeselthet s valid allsin►Y is as Jils he hose penile or Sanyo A new amdntit sett be Mid.et.ach
years When s hoar owsa.rclan is°bulldog a license arpomk aataleend tssay business asconna.W Glans
(Le.a dog awns or peon to bone haves ear.)slid pesos is NOT ranked to cowgirls this.mdevit
Tb.OAIn otravaelptiam would like le theek Joe in advueoe kr percoope attoe sod should you ben say gwstione,
phase de not hookas to live us call
Ilia Dep rs■eat's address,t.kpbrae sad he numbs:
The Commonwealth of Massachusetts
Department of Inludlial Accidents
oak.of wall__ese
600 Washington street
Boston.MA02111
Tel.0 617-727-490O at 404 or 1-$77-MASSAFg
Revised 1 1-22a16 fax M 61 7-7Z7-77�t9
wwwnmv.guv/die
ut/uvrAuti 18:4r.tp FAX 1508430111S+
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Ad�ei a copy'Elbe workers
F r rba prayatlar p l,h.�.,__ 0'ion p +=
° ono•your imptionnment.on weii as civll ponnitios in the tint ofa STOP wORZ ORDER an d a Sao crop ft$250.00 a
d"°d utterMGL a 152.USA is a criminal on n � �ishable by a Ens up so$1400.00
day Now the violator.A copy red*xatemeat May be totnenisd to the Office offaveadgatioas addle DIA far abaavaaa*
`n f i4-,,.p..
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4w,' r� Office of Consumer Affairs and Business F�eG�g o �� .
_ 10 Park Plaza-- Suite 5170
' • Boston
, Massac efts ail 16
Home Improvement ``=R' �0- tor Registration.. - .
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Cenuitenwealdso., ,
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McGRATH POST& BEAM CO. ., F_mt.-
Board of , ,�Standwds
J�1 ES McGRATH * .......:� ,-.1, _' _
259 QUEEN ANNE RD. •_ = csFA-073865 �... �j
HARWICH,MA 02645- ___._ � yre s:�y� ,�o
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Office of Consumer Affairs and Business Regulation
1000 W :�,6 n Street-Suite 710
Boston, `r usetts 02118
Home Impro = --, . . : .-,.r Registration
Type Corporation
MCGRATH POST a BEAM co. `' -_ 132935
— Eoiratior>: 1Q13QR020
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ovarA PE HARBOR WOOD PRODUCTS ! = =—
259 QUEEN ANNE RD.
HARWICH,MA 02645 4*.4�ai
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:A t 0 asr asrn Update Address end Return Card.
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HOME - • , W CONTRACTOR Registration void for Inmwder use only
before Moe of thCaweaerAM**04011110011 dill. W blind return tsc
MC�;RATH • ReguNtion
1_ �`' '01362020 MO 001000,MA abest-Salts710
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,rJAMES R. .a-."'_I __
259 QUEEN ANNE • -HARWICH.MA 02615 Undersecretary Not valid without algomatrare
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ACORU#`,.,...� CERTIFICATE OF LIABILITY INSURANCE �� n
7/82019
THIS CERTFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON TIE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER TIE COVERAGE AFFORDED BY TIE POLICES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN TIE ISSUING INSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(es)must have ADDITIONAL INSURED provisions or be endorsed.
IT SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may req**e an endorsement A statement on
this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
ppPaoDIN RliteCT
►insurance Agency,Inc. P!1pf�
43�iRhs 134 WIN E (800)553-1801 1 F ru(877)816 215B
South Dennis,MA 02660 ass:mall@rogeregray.com
INSURER(S)AFFORDING COVERAGE ERNAC t
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I ',SURA:Travelers Indemnity Company 25658
OMEO mum's:New Hampshire Employers bounties Cowan 13083
M1cGrslh Post trim 4� ` pSORERc
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INDICATED. NOTWITHSTANDING ANC MENT CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH TENS
CERTIFICATE MAY BE ISSUED OR .,,. AIN, TH AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH .. LICIES.LIMITS,SH •Y HAVE BEEN REDUCED BY PAID GUMS.
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POEM/EFF PONCE/EXPLrN TYPE OF INSURANCE oR INs n n MOTS X cc ERC*ALGENERAlmum, OCCURRENCEEACH 1,000,000
cuAsrs.MADE X OCCUR i-860-�498-IND-1 '' 1/31/2019 1/31/2020 ,ce) $ 100,000
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GEN L AGGREGATE Lii* t GEra:RAL AGGREGATE $ 2,000,000
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ANr PROPRIETORRNa�rneRA x>curlvE yAND EMOTION,'moony vf ECC4r4> r' 18A 7 1,,si" x iA'.' srArutLx t[t
��i� IYtng DCCLUOED? N%A. /BIZO1a;. ' � $
500,000
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DESCRIPTION OF OPERATIONS below ti 1; `v rtr c k 9, EL DISEAS4a.�Y 500,000
DESCIernoN OF OPERATIONS/LOCATIONS/YOWLER(ACORD 101,Additional Remrks Schedidialnwite.,NNTEEM0ITT.Peee is r eat
CERTMRCATE HOLDER CANCELLATION
SHOMRD ANY OF TIE ABOVE DES PO(JC ES BE CANCELLED BEFORE
Town of Yarmouth 'THAACCORDANCE WITH POU EXPIRATION DATE UCCY P THEREOF,
I NOTICE SIONs WILL BE DELIVERED ea
Building Dept
1146 Mein St,Route 20
South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE
ACORD 25(2016103) 0 1988 2015 ACORD CORPORATION. Ali rights reserved.
The ACORD name and logo are registered marks of ACORD