HomeMy WebLinkAboutBld-20-001835 d4 `4',k, Office Use Only
.a \ OCa Permit#
0 e� .)yfp Amount
\?•c..:e?i =-„* Permit expires 180 days from
k1 � a' issue date
EXPRESS SHED PERMIT APPLICATION::;—,::
TOWN OF YARMOUTH
,
Yarmouth Building Department
1146 Route 28 OPT ! 4 209
South Yarmouth,MA 02664 t t
(508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS: I S r✓ be rrl,
ASSESSOR'S INFORMATION:
Map: Parcel: •
OWNER: -3i S - Cc�, ,;�.c l�s C ;- - C►mkrr, /114- vista Sa8- 3t -ybt�
NAME PRESENT ADDRESS TEL. #
CONTRACTOR: Pc`- VVBDdluiy'K-049—, U1C_ l/2? R.d Oct iiiltC VI+ O.P1`1 " 71/-7<133
NAME MAILING ADDRESS TEL.#
Ll Residential ❑Commercial Est.Cost of Construction$ 7, Sky- 2'7
Home Improvement Contractor Lic.# Construction Supervisor Lic.#
Workman's Compensation Insurance: (check one)
I am the homeowner 1 I am the sole proprietor _: I have Worker's Compensation Insurance
Insurance Company Name: Worker's Comp.Policy#
SHED INFORMATION
New ✓ Size L I'( x W IQ x H (0 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:
Location of Facility
I declare under penalties of perjury that the statements herein contained arc 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 y license and for prosecution under M.G.L.Ch.268,Section I.
Applicant's Signature: z Date: io,'gl
Owners Signature(or attachment) �i Date:
Approved By: � Date: /O7.'-4V
Buildi Die. or signee) E ..ADDRESS:
Zoning District:
Historical District: 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
The Commonwealth of Massachusetts
=�=, 1=el Department of Industrial Accidents
w = 1_ 1 Congress Street, Suite 100
‘.* ='tf- /3' Boston, MA 02114-2017
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/Individual): ��+' 5� ,,,,,,".. ti►►
Address: cr Q ox. r r
City/State/Zip: we; , M; 0;16,7 3 Phone#: SUs - l -ss-v
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
2.0 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 doingall work myself. 9. ❑Demolition
❑ ys [No workers'comp.insurance required.]t
4.0 I am a homeowner and will be hiring contractors to conduct all work on my property.ro 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.
12.0 Plumbing repairs or additions
5.Q 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 certi under t pains and penalties of perjury that the information provided above is true and correct.
Signature: Date:
Phone#: Job' 5 3i —s=oi y
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#:
44 • PLOT PLAN
•P. •
FOR LOT I
Indicate location of garage or accessory building
Additions with dashed lines
Sewerage disposal (cesspool) EB
Well
I
I
(lot ft. rear)
Abutbor•s
Name I Abuttor'
Got l ' Name
6' 1 Lot l
f this isa -N-
REAR YARD
er lot, Pt. ED" If this
:arn
grits in name 1
cwrit r
street. write of
name
I i other .
: SIDE YARD
HOUSE 1
SIDE YARD •
•
. •
.
.
. .
. ?
•
•
. I
I _OA
: ,, --.2----
I .
SET BACK • ,S
•
ft. .
4
1 4 I
���iiii
I
(lot ft. frontage)
\ // 11' ROnkzerr?.. Le,
(NAME OF STREET)
information
` Supped by Job S 5Cc-,✓emu tip
LARK NORTH POINT