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Home My WebLink AboutBld-20-003042 ��- SHEDS LESS THAN 150 SQ FT SHALL BE - Office Use Only :41b, PLACED A MINIMUM OF 30 FEET FROM THE Permit# \Ci FRONT LOT LINE AND A MINIMUM OF 6 FEET CA Jti FROM THE SIDES AND REAR LOT LINES Amount �NAITACF L1[J�.y�T7� Permit expires ISO days from issue date EXPRESS SHED PERMIT APPLICATION. TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: A ati7`41 �c_ ' i G,ty y ASSESSOR'S INFORMATION: Map: Parcel: ow'N.ER:/" lj� ,//1_ `'�Lc� e►' 4J60,. /2" 0 Gl Ze e)- ✓ l / NAME PRESENT ADDRESS TEL. CONTRACTOR: /99 j 4/241..gui1��/L4._ e „ Ift L e/l I 9 V NAME MAILING ADDRESS TEL.It esidential ❑Commercial Est.Cost of Construction$ Home Improvement Contractor Lie.m / / "/ 319 Construction Supervisor Lie.n r1 3/40 -2 Workman's Compensation Insurance: 'heck one) i I am the homeowner _'✓I am the sole proprietor f_ I have Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy# SHED INFORMATION New Size L x GV x H Corner Lot: Yes No Per Town of Yarmouth Zo/iine Bp-Law Sec 203.5 E: Side and rear setbacks for accessory buildings less than 150 square feet and single story, shall he 6 feet in all districts, but in no case built closer than 12 feet to any other building. Replace existing* Size L x 1•V 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 answerts) will be just cause for denial or revoc'tion of my I.-ease and for prosecution under M.G.L.Ch.268.Section 1. Applicant's Signature: eai Date: Owners Signature for attachment) .24, i ( • 'hjryDate:..----------___..-- '-r Approved By: _ Date: Building Official for designee) EMAIL ADD ESS: — — Zoning District: Historical District: Yes Li No Flood Plain Zone: Fi Yes No Water Resource Protection District: Within 100 ft.of Wetlands: Yes L. No YS_s No ***Note:Conservation review required if within 100 R of Wetlands q;t' 1 Office of Consumer Affairs&Buslness Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Individual r i 01/30/2021 6 , STEPHEN PR ' '' as r1 STEPHEN W.Pfi 19'DEVONSHIRE LANE` ��3 3� SOUTH DENNIS,MA 02660 Undersecreta ,. 'Y-.-..-_ ... ,� ..._............. .� .._a .... w,. ( Commonwealth of Massachusetts Division of Professional Licensure r 9 Board of Building Regulations and Standards Const1 ICttiri ltdpFrvisor I CS-113107 - Ra Nt�ires: 11/17/2022 ' STEPHEN W PRUN 1ri t 19.DEVONSH I ' SOUTH DENNI AAA 1 ' 'I X Coi'nmissioner - o • _- c vuiCe use Amy Permit ['Amount l � .— V7 [sE d I 4`*"""`°»Q c� Permit expires 180 days from i issue date SC)-aO-(3�- , EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH NI iV Yarmouth Building Department CAS �yn 1146 Route 28 1-1- . South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 V CONSTRUCTION ADDRESS: v6e�t/ ASSESSOR'S INFORMATION: Map: ,%, /Parcel: c �n l/ OWNER: /44,44) ' 3.F Z !�'� t��0NAME ` //�7/) PRESENT ADDRESS TEL. # 1 CONTRACTOR: V t - /;t/✓' < ? � z_A,/,i 4,, `fi �-�t)/ C' '`0? -,/ j NAME MAILING ADDRESS "� TEL.# esidential 0 Commercial Est. Cost of Construction$ 5 _ ', Home Improvement Contractor Lic.# i r03 C`6 Construction Supervisor Lic.# //31(.)) Workman's Compensation Insurance: (check one) I am the homeowner [;)/am the sole proprietor ❑ I have Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy# WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate attached?) Wood Stove Siding: #of Squares Replacement windows: # Replacement doors: # Roofing: #of Squares �) ( )Remove existing* (max.2 layers) Insulation V Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing *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 ,. l* ense and for prose ion under M.G.L.Ch.268,Section 1. Applicant's Signature:a �'.�/'1�� ,(n,�� Date: y:z�� % C Owners Signatu (or att. hme I ump Date: /` • ' / , // Approved By: i ._ _ . Date: ' Building Official(or designee) k EMAIL ADDRESS: Zoning District: Historical District: ❑ Yes Li No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No 0 Yes 7_ No The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 ��M„�5�•`''� www.mass.gov/dia \Yorkers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): _S-1 ,, n�,�� Address: /7. 4Vin r4)41 G,/) City/State/Z it � ) /Md D 2 Phone #: 2(di -' , lv Z"'(�73V Are you an employer?Check the appropriate box: Type of project(required): I. I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling any capacity.[No workers'comp. insurance required.] 9. ❑ Demolition 3.❑I am a homeowner doing all work myself. [No workers'comp. insurance required.]t I0 Building addition 4.C 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.E 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.% 6_E We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other (52,§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. ' 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. n: 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 ains an penalties of perjury that the information provided above is true and correct. S ianature: Date: /l �-Z e /jam Phone#: /7e/1 d2 --1)3 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#: