HomeMy WebLinkAboutBld-20-394 Ns SHEDS LESS THAN 150 SQ FT SHALL BE Office Use Only
PLACED A MINIMUM OF 30 FEET FROM THE
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(..' ) FRONT LOT LINE AND A MINIMUM OF 6 FEET
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a\,'",av*',„,,V Permit expires ISO days from
'issue date
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EXPRESS SHED PERMIT APPLICATION
TOWN OF Y-ARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664 /
(SOS) 395-2231 Ext. 1261 G tl,
CONSTRUCTION ADDRESS: ' it l- / " Ill
ASSESSOR'S INFORMATION:
Map: Parcel:
OWNEI : i c/ku(e % h� ,-1. (cam-0 -1-1�-2. --- 6 gl"1
NA IE PRES NT ADDRESS TEL. 4
CONTRACTOR:
NAME MAILING ADDRESS TEL.
❑Residential 0 Commercial Est.Cost of Construction$
Home Improvement Contractor Lie.4 Construction Supervisor Lic.R
Workmanompensation Insurance: (check one)
Vt am the homeowner 2 I am the sole proprietor L I have Worker's Compensation Insurance
Insurance Company Name: Worker's Comp.Policy#
SHED INFORMATION
New Size L 20 x W j ID x H CornerLot: Yes No�
Per Town of Yarmouth Zoning By-Law Sec 203.5 E:
Side and rear setbacks for acce.ssosy 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.
40
Replace existing" Size L x PY x H
*The debris will he disposed of at:
Location of Facility
I declare wider penalties of perjury that the statements herein contained are true and correct to the best of my knowledge and belief. I underst:u,d that any false answers;
will be just cause for del' vocs . ise and for prosecution under M.G.L.Ch.268.Section 1.
4471
Applicant's Signature ti • Date: 1 c1
7 v
Owners Signature(or attachment) Date:
Approved By:-- Detc: ') 'd -1
L.
Building Official(or dcsi<ance) EMAIL ADDRESS:
Zoning District:
Historical District: Yes No Flood Plain Zone: Yes is No
Water Resource Protection District: Within 100 ft.of Wetlands: :;::,`
._ Yes LI.. No 11 Yes No
***Note:Conservation review required if within 100 i1.of Wetlands
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m i c k e • ora s 1 g fylvd' (,o44-,
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. The Commonwealth of Massachusetts
° =* Department of Industrial Accidents
1 Congress Street, Suite 100
vatf_ " Boston, MA 02114-2017
v.s.•�'� www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/-ndividual): (ra)r
C Th
S1
.9 Address: / üc _d_
City/State/Zip: , rffitd1 Phone #: u -714_ 6 D L
Are you an employer?Check the appropriate IR Type of project(required):
1.❑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
zr apacity.[No workers'comp.insurance required.]
9. ❑Demolition
3. m a homeowner doing all work myself.[No workers'comp.insurance required.]t
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.❑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
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c.
14.El 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 e pai 1-----idlynalties of perjury that the information provided ab ye is tru and correct.
Signatur �/t Date: /6' ' i C
Phone#: I i 4 t
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. BuiIding Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
z.
, • •
PLOT PLAN
FOR LOT #
Indicate location of garage or accessory building
Additions with dashed lines
Sewerage disposal (cesspool) ES
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I (lot ft. rear) J
Abutter's 42_� - - -
Name Abutter'
Lot # ! LName
ot #
a this is a ' :v•`-� •
corner lot ' If this
vrite in name �J corner :
'f street. write i,
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t! ,�w street.
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: SIDE YARD
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SET BACK :
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(lot ft. frontage)
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(NAME OF STREET)
Information
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