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Home My WebLink AboutBld-20-4431 .OT y fficc Use Only �'` -'� 4�` - o�f'd111'y 3/ �.,hr`-�e e t!\ Amount rid Permit expires 180 days from issue date EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 / (508)398-2231 Ext. 1261 CONSTRUCTION ADDRESS: P IV#4a4,-4 h4ue A,//J• / �A.‹,iiva A/ Wit 024 73 ASSESSOR'S INFORMATION: `V/ Map: Parcel: l /v OWNER: -JCHAI AU',AU', 7 x54/L� dcda #4mbAteoe. / le-lo ll 7-`l�4�6a NAME y PRESENT ADD RE TEL. # CONTRACTOR: NAME MAILING ADDRESS TEL.# 1Pesidential ElCommercial Est.Cost of Construction S 140 i Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) XI am the homeowner T I 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 Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing SN F � b t/`r49 *The debris will be disposed of at: 4/V de vede 7-'tQ4,. t4.01/3 Location of Facility t/ 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 r prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: .h. A. �t 1 1 Date: L�//[p L Owners Signature(or attackmen t t Date: a(/AC e-' i /. ' f i ��t Approved By: �I LA-4�c (�I��IC�Q— c �" te: Buildin Official o i AIL ADDRESS: Zoning District: Historical District: Yes No Flood Plain Zone: re Yes No Water Resource Protection District: Within 100 ft.of Wetlands: Yes No Yes '. No . The Commonwealth of Massachusetts '._ _= ,—_"/ Department of IndustrialAccidents =_=+n== = 1 Congress Street,Suite 100 =�1- '� Boston,MA 02114-2017 ,,,' www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. ,Applicant Informatioji Please Print Le[bly Name(Business/Orgenizatiodlndividual): (J e//tj PF,cie Address: e J l 41.- 4,A /AA)e f We(t )t6 *T i At City/State/Zip: .6,40; j/ 04 73 Phone#: �17F- 4.7- VIZ) d Are you as employer? eck the appropriate box: Type of project(required): l.❑I am a employer with employees(!fill 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.] ❑ 3.❑I am a homeowner doing all work myself[No workers'comp.insurance required.]t 9. El Demolition 4. I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 El Building addition ensure that all connectors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees, 12.❑Plumbing repairs or additions 5.0 II run a general e sv antractor have d I have hired the sub-contractors listed on the attached sheet. 13.Q Roof repairsThe 1 ❑ employees and have workers'comp.insurance.* 14. Other Si e Q 6. We are a corporation awl its officers have exercised their right of exemption per MOL,c.15Z 111(4) 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 em•ogees. If the sub•antreotors have employees,they must. • their workers'comp.policy comber. ---- I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and Job site informadlon. Insurance Company Name: Policy#or Self 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 S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 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 cat*j►under the pains penalties of perjury that the information provided above is tare and correct, 14-14-• 5ianature: A • Gi, Date: Z % 142Z.0 Phone#: et7s' j 7''ASV C Official use only. Do not write in this area,to be completed by city or town o idal 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#: PLOT PLAN • • t,• • FOR LOT # Indicate location of garage or accessory building Additions with dashed lines Sewerage disposal (cesspool) Well (g i I (lot ft. rear) OMMIMED WOW.* J Abuttor's Abuttor' Name I Name Lot s Lot t REAR YARD :f this is a --^ If this orner , .,.fr�.61.. ..rt. corner mile in name , I write i tf street. name of other Z • SIDE YARD SIDE YARDHOUSE • : 00 CPO mot ' SET BACK : I � a (lot ft. frontage) .\doGoktor (NAME OF STREET) ♦ Information / • Supplied by ARK NORTH POINT .•".6;1.Y4R Office Use Only $.: ``. Permit# �j� i H, Amount 3 5'" V ' '� .urr'in s "Z. -;�,' a..rc• ��,.• Permit expires 180 days from issue date EXPRESS SHED PERMIT APPLICATION pC — TOWN OF YARMOUTH ,' ; Yarmouth Building Department EP15t 1146 Route 28 j i South Yarmouth, MA 02664 I �i' _�'iG � (508) 398-2231 Ext. 1261 CONSTRUCT ADS IsSS: 8 i V; A C7 R RA 1-- Iv VI c 1 /,a t?N1 J i i ASSESSOR'S INFORMATION: i pe Map: y Parcel: �W' OWNER: L ` N R RY ) 7 i� /' 1-E y &I) 1_I'J boJ C R G/ /O NAME PRESENT ADDRESS TEL. # CONTRACTOR: S . An(,)6 L G 1 0 1 J S B S1 MAIN 51 I `I•h N l S 1 1 4 810 S 3-4 5 NAME MAILING ADDRESS TEL.# t Residential D Commercial Est.Cost of Construction$ Cow5 / 3 0 O �j Home Improvement Contractor Lic.# Construction Supervisor Lic.# S I 0 -t Workman's Compensation Insurance: (check one) I I am the homeowner sL.I am the sole proprietor ❑ I have Worker's Compensation Insurance Insurance Company Name: 1 i v i I j :- Worker's Comp.Policy# VW C.1°0-6oJ9`1 o; Cif A SHED INFORMATION t hh New Size L"�41 x W 10 x H 12 Corner Lot:Yes 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: b A f J S 1 A b Le •�,(J M P 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 re y license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: r` Date: 0/ j.o _)-001,0 Owners Signa re(or attac ment) Date: Approved B • Date: But din ici ee) EMAIL ADDRESS: Zoning District: Historical District: Yes -; No Flood Plain Zone: Yes [ No Water Resource Protection District: Within 100 ft.of Wetlands: *** L Yes '- No Li Yes No ***Note:Conservation review required if within 100 ft.of Wetlands 9/13