HomeMy WebLinkAboutBld-20-000823 •
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SHEDS LESS THAN 150 SQ FT SHALL BE j e Use my
of ��` PLACED A MINIMUM OF 30 FEET FROM THE Ma 00
FRONT LOT LINE AND A MINIMUM OF 6 FEET
{0� ON
" .-I °,l��x FROM THE SIDES AND REAR LOT LINES Amount
1 h).TTACF LSE„',j
`�' sut: Permit expires ISO days from
issue date
EXPRESS SHED PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664
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(508) 398-2231� Ext. 1261
< `� "^'CONSTRUCTION ADDRESS: 1 J' 1J ad `,'` ,�s 4 y c c 1" 1 Oo 6 )3
ASSESSOR'S INFORMATION:
Map Parcel: U 4,1• gc
OWNER: kço is i5 V W Y 911
---77s ' -2s-
NAIVE / PRESENT ADDRESS TEL. et
CONTRACTOR:
NAME MAILING ADDRESS TEL.#
Residential 0 Commercial Est.Cost of Construction$ LOW
Home Improvement Contractor Lic.# Construction Supervisor Lie.#
Workman's Compensation Insurance: (check one)
j1 I am the homeowner _ I am the sole proprietor 0 1 have Worker's Compensation Insurance
Insurance Company Name: Worker's Comp.Policy#
SHED INFORMATION
New Size L x Ill x H Corner Lot: Yes No /c AUG 13 2019
Per Ton'n of Yarmouth Zoning By-Law Sec 203.5 E: BUILDING DEPARTMENT
•
Side and rear setbacks for accessory buildings less than 150 square feet and single story, shall fie : Y -- -, _ •
in no case built closer thanth 12 feet to any other building.
Replace existing* V Size L ( _x i'v I0 x H
*The debris will be disposed of at: 1 c. -1 Tall
Location of Facility
I declare under penalties of perj ••that the s aments It ein cunt, ed are true and correct to the best of my knowledge and belief. I understand that any false answers;
will be just cause for denial o�r' cation o m•license Id for p •eeution under M.G.L.C.h.263.Section 1.
Applicant's Signature: li, z 1 n Date: Q V ✓ ��
Owners Signature(or attachment)k... ✓) rii���/// /� — Date:._.._.__'%� : 1/
Approved ay: --- Date: — 13 - I5
[Building Official(or designee) EMAIL ADDRESS:
— Zoning District: i
Historical District: 1 Yes No Flood Plain Zone: Yes No
Water Resource Protection District: Within 100 ft.of Wetlands:;<:"'-
No-Yes_ ..
'_ Yes No
***Note:Conservation review required if within 100 ft.of Wetlands
9113
4.
_ The Commonwealth of Massachusetts
* , _�� Department of Industrial Accidents
".-- 1 Congress Street, Suite 100
�
I_ Boston, MA 02114-2017
y'$V www.mass.go v/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): J u{M.e-1'r 16ei
Address: -7 5— Lew Ls (LI uLte,s4 yaks,t A , Ma 04403
City/State/Zip: Phone#: 7 S- 33 )3
Are you an employer?Check the appropriate box: Type of project(required):
1.0 I am a employer with employees(full and/or part-time).* 7. ❑New construction
2.❑I am a sole proprietor or partnership and have no employees working forme in 8. Remodeling
an capacity.[No workers'comp.insurance required.]
3. I am a homeowner doingall work myself. t 9. El Demolition
y [No workers'comp.insurance required.]
10 ❑ Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions
proprietors with no employees. 12.0 Plumbing repairs or additions
5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs
These sub-contractors have employees and have workers'comp.insurance.t
14.["Other (�l' ALA$fi -,. ,,
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. ��" _t
152,§I(4),and we have no employees. [No workers'comp.insurance required.] S hPd[ f>"c S l w ,1 S f !u rnc,.J
*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 certif 4 it ` er the i s and p aid :of perjury that the information provided above is true and correct.
i
Signature: L.3,1 ,t p Date:
Phone#: �ti 5"- - ;3i j
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#:
•
,x.
PLOT PLAN
FOR LOT # 0 C)' Ei'
Indicate location of garage or accessory building
Additions with dashed lines
Sewerage disposal (cesspool)
WeLL igi
II
I (lot ft
_ _ • ram, I
Abuttor's
t 'fl• — — -
Name Abettor'
Lot # ae' "� Name
. R r ) �- �17 Lot #
f this a REAR YARD
garner lot, If this
ft
trite in name I corner
'f street. I
write ii
, name of
°i a other
11
,3 street.
: SIDE YARD
SIDE YARD ••
HOUSE .
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• •
••
•
• t •••
• f •
•
SET BACK
•
ft.
A
I
a
(lot ft. frontage)
c- L
(NAME OF STREET)
Information
/ \ Sopped by
LARK NORTH POINT