HomeMy WebLinkAboutBld-20-003155 `;'-'r" , FS THAN 150 SC':•. F i >r-`;1{ Office Use Only
p��YyR A M,NIi,,1 JM OF 30 "r E:T
�+ a,t re 0V THE." r'iO vT LOT LINE.AND A Permit#
'y iN UM OF 6 FEET FROM SIDES AND Amount 35
�••«�•' 6 I Permit expires 180 days from
��� tJI`CJ issue date
1
EXPRESS SHED PERMIT APPLICATION {
TOWN OF YARMOUTH
Yarmouth Building Department NUtt
1146 Route 28
South Yarmouth,MA 02664
(508) 398-2231 Ext. 1261 #. ,,
CONSTRUCTION ADDRESS: I 7 /7- Ter $ 2, `/a r M e)a/L 1
ASSESSOR'S INFORMATION:
Map: Parcel: c,
OWNER: OA V J ILL 1-6.l eel (3 7 -td y wc& 7(St'— 6 Y I s ! 4
NAME (y PRESENT ADDRESS Y TEL. #
CONTRACTOR: pl(.o1 r- •eeN 44ii RJ, HarwicL 5"2Y—
NAME MAILING ADDRESS TEL.# 4130_ c6"L/
Residential 0 Commercial Est.Cost of Construction$ j 3 OC)
Home Improvement Contractor Lic.# H L t 1 ;5— Construction Supervisor Lic.# 07 34r s
Workman's Compensation Insurance: (check one)
t am the homeowner 0 I am the sole proprietor S I have.Worker's Compensation Insurance
Insurance Company Name: Worker's Comp.Policy#
SHED INFORMATION
New Size L ICJ x W `S x H 10 Corner Lot:Yes X No
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 W 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 revocation of y license and for prosecution under M.G.L.Ch.268,Section 1. /r1
Applicant's Signature: %'�'/ Date: I I( 2 7
/Owners Signature(or attachment) � ( Date: I I (2 7 // Gi
Approved By: Date: I\ l c1
Building Official(or designee) EMAIL ADDRESS:
Zoning District:
Historical District: L Yes C No Flood Plain Zone: Yes No
Water Resource Protection District: Within 100 ft.of Wetlands:***
[1 Yes No n Yes .._ No
***Note:Conservation review required if within 100 ft.of Wetlands
9/13
The Commonwealth of Massachusetts
A fi Department of Industrial Accidents
1 Congress Street, Suite 100
=Vy Boston, MA 02114-2017
www.mass.gov/dia
\Yorkers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information ]( Please Print Legibly
Name(Business/Organization/Individual): Me ({t}h �� CT i 13ca[) r_ k'}1(
Address: asq Cuter) Anne. Tocttl
City/State/Zip: Harwich eh (VIA 01(D y' Phone#: 5081430 a800
Are you an employer?Check the appropriate box:
Type of project(required):
1.0 lam a employer with employees(full and/or part-time).° 7. 0 New construction
2E1 I am a sole proprietor or partnership and have no employees working for ` 7 Remodeling
any capacity.[No workers'comp.insurance required.] ,�S ' .0?
3.01 am a homeowner doing all work myself[No workers'comp.insurance required.]'
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 l 1.C3 Electrical repairs or additions
proprietors with no employees.
12.El 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.:
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q 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.
tContractors 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.
l am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: New Htterpshite Empic*j rs ]fora ril e rarnputi
Policy#or Self-ins.Lie.#:FCC '(ppp-LI UQDIS 7 —dp I BA Expiration Date: J(I A t )( (�
Job Site Address: City/State/Zip: 'i
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$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
do hereby certrfy u r he pains an e , s o aim), t e information provided above is true and correct
Signature: Date:
Phone#:
Official use only. Do not write in this area, to be completed by city or town oOcial
( City or Town: Permit/License#
Issuing Authority(circle one):
I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Iispector
6.Other
Contact Person: Phone#:
e$• •
•e4 •. PLOT PLAN
FOR LOT #
Indicate location of garage or accessory building
Additions with dashed lines
Sewerage disposal (cesspool) ED
Well 0
I
! I) I
(lot..1.i.11 ft. rear)
Abuttar's <> .1
NameI 6_� 6 Abuttor'
I
Lot # - Name
1)--i Lot #
f this is a
REAR YARD �G
orner lot, If this
trite in name i f t. I corner
f street. I write 1
name of
p other
ti street.
cl
: SIDE YARD
I �( 1 � HOUSE SIDE jARD •
d-- a_ _ �
•
•
.
c, .
•
: SET BACK
• D •
. 3 i
4
'
,p
(lot" 1 c2 7 ft. frontage)
/ — r_
/
(NAME OF STREET)
Information q
•
Supplied by 01/1 i
LARK NORTH POINT
;✓fie to . o ,7nadoiczoluedeea
t' .` Office of Consumer Affairs and Business Regulation •
f r ' 10 Park Plaza- Suite 5170
Boston, Massac a.,setts 02116 ,
Home Improvement 441/,_; tor Registration
a Commonwealth of Massachusetts
'�" ---� Division of Professional Licensure
� _ Board of Building Re ations and Standards
McGRATH POST& BEAM CO. — " construction, i $pr_1 &2 Family
JAMES McGRATH :` «� �!
t.
259 QUEEN ANNE RD. ==__ CSFA-073865
4 ires:03/141�l20
HARWICH, MA' 02645" '� _..__ — t '
7 mar JAMES R M o ',ft' i't., ,,,
....0 = �, • 204 CRAf1VJEY11
M — ,..116BREWSTER r';,. I V-
III
wA.u,nir..n.,.aU1SS"i��c1
Commissioner a„, dee.-00-
•
Office of Consumer Affairs and Business Regulation
1000 Washing •n Street-Suite 710
Boston, M-~� husetts 02118
Home Improve w- ._ , tractor Registration
h y -
v Type: Corporation
MCGRATH POST 8 BEAM CO. ;:�„ to Registration: 132935
D/B/A PINE HARBOR WOOD PRODUCTS _le _ t'�� w Expiration: 10/30/2020
259 QUEEN ANNE RD. . � _ •� 'a
HARWICH,MA 02645 :'. f
W ti
SCA I 0 20H.05/17 Update Address and Return Card.
Office of Consumer Affairs&Business Regulation
HOME IMPRO 4 ENT CONTRACTOR Registration valid for individual use only
., • '" .on before the expiration date. If found return to:
10/30 Office of Consraner Affairs and Business Regulation
1 1000 Washington Street-Suite 710
MCGRATH Pv``yy,,_ si..._-.� Boston,MA 02118
DB/A PINE H y`1�-=__: ,;._-_ 0.ODUCTS
- r
JAMES R.MC
259 QUEEN ANNE ''-
HARWICH,MA 02645 Undersecreta Not valid without signature
ry
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