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HomeMy WebLinkAboutBld-20-003087 r ., Office Use Only ��..Y4,4-� SHEDS LESS THAN 150 SQ FT SHALL BE ,� PLACED A MINIMUM OF 30 FEET FROM THE 02©is s FRONT LOT LINE AND A MINIMUM OF 6 FEET 0t lti FROM THE SIDES AND REAR LOT LINES Amount K,,_.,,,,,,A2,4- F cs1/$7, 1'*aiv""' :Permit expires ISO days from issue date EXPRESS SHED PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 57 L—(.5�ri� 5, �!,„7 L ASSESSOR'S INFORMATION: Map: 3 y Parcel: /3 OWNER: 1I•L:1-1 1,abv..L.---7, S—Y CLOz2- 5r �v� :, Alq_- '�6-2-3 -�Yb1�z NAME PRESENT ADDRESS TEL. # CONTRACTOR: IAA./ oa, NA tE MAILING ADDRESS TEL.# l f(tesidenti.al 0 Commercial Est.Cost of Construction$ ,SO `•��11 J Home Improvement Contractor Lic.# Construction Supervisor Lie.# ((!! Workman's Compensation Insurance: (check one) YI'am the homeowner 0 I am the sole proprietor C I have Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy# SKIED INFORMATION New ✓ Size L to / x (V 1/ x H ivr t/ Corner Lot: Yes No ✓ Per Town of Yarmouth Zoning By-Law Sec 203.5 E: 1 R F c, E V F D Side and rear setbacks for accessory buildings less than 150 square feet and single story m,shgrll i e.6 feet in-ct 1 disrrrict. but in no case built closer than 12 fret to any other building. : l NOV 26 2019 Replace existing* Size L x IF x H 4 1 B DING i,,ri-,,i-,R14 gsb *The debris will be disposed of at: f'r 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.263.Section 1. Applicant's Signature: __—__-- Date: 00,4 „z_f —/ S Owners Signature(or a tachunent) I w.. Date: _—t ct Approved By: d� / Date: /! 2C Bull ' _0 ial(or esigncc) IA[L ADDRESS: Zoning District: Historical District: 1 Yes No Flood Plain Zone: Yes No Water Resource Protection District: Within 100 ft.of Wetlands: *** Yes No Yes No *' *Note:Conservation review required if within 100 ft.of Wetlands 9/13 I _ The Commonwealth of Massachusetts ►�",;_, _ /, Department of Industrial Accidents _e,1el= 1 Congress Street,Suite 100 1__ �� Boston, MA 02114-2017 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): i\ E44-j .-i-c1lai/i&' lfl:,,e,, Address: y e --A 4a sr— City/State/Zip: b?ft..-,s,,",A `V),r v 'Phone#: (-5-2,.g- —360 _ 4,z, Are you an employer?Check the appropriate box: Type of project(required): LEI 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 a capacity.[No workers'comp.insurance required.] 9. ❑ Demolition 3. I am a homeowner doing all work myself. [No workers'comp.insurance required.]t ,,,. 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 ❑ Building addition 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.: 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 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 pains and penalties of perjury that the information provided above is true and correct. Signature: dLi. ..., Date: 'W -i-" —tc..) Phone#: I 5O —3 —`tobz, 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#: I r . . 44 • PLOT PLAN FOR LOT # Indicate location of garage or accessory building Additions with dashed lines Sewerage disposal (cesspool.) 69 Well 0 I II I (lot ft. rear) 4 f Abuttor's Name ( Abettor' Lot N Lot # this is a REAR YARD v' corner lot, ft If this vrite in name 1 corner - 'f street. I write f name of ,0, w other v b street. • SIDE YARD SIDE YARD . • HOUSE 1__ _ _ T* E (1----- Dif) : . . I . SET BACK I .14 (lot ft. frontage) \ 4 - e e S (NAME OF STREET) / `/ Information Supplied by PARK NORTH POINT