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`Permit#
` S O -e-!, H t Amount
Permit expires 180 days from
EXPRESS SHED PERMIT APPLICAIT®N-, 2019
TOWN OF YARMOUTH
Yarmouth Building Department .A. r
1146 Route 28
South Yarmouth,MA 02664
(508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS: ')Y"L 4 4 2 IA5... etano L )72A-toz,
ASSESSOR'S INFORMATION:
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to Map: �fParcel:OER: i I�YI� !tr L u )4NPRESENT AD RESS TEL. #
CONTRACTOR:
NAME MAILING ADDRESS TEL.#
❑Residential 0 Commercial Est.Cost of Construction$ Li-weir-0o
Home Improvement Contractor Lic.# Construction Supervisor Lic.#
Workman' ompensation Insurance: (check one)
am the homeowner ❑ I am the sole proprietor 0 I have Worker's Compensation Insurance
Insurance Company Name: Worker's Comp.Policy
SHED INFORMATION
New Size L /12 x W / x H 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 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.268,Section I.
Applicant's Signature: Date:
Owners Signature(or attachment) Date: 42
Approved By: Date: 11,-14 -15
Building Official(or designer - EMAIL ADDRESS:
Zoning District:
Historical District: ❑ Yes t_' No Flood Plain Zone: C Yes U! No
Water Resource Protection District: Within 100 ft.of Wetlands:***
L Yes r' No 0 Yes No
***Note:Conservation review required if within 100 ft.of Wetlands
9/13
. The Commonwealth of Massachusetts
In t'/ Department of Industrial Accidents
=�I1� . P
_:11'1l= 4 1 Congress Street,Suite 100
_ilif.. S' Boston,MA 02114-2017
�^7..,;,,, www.mass.gov/dia
Wiorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH TUE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): ..„. 1 t,1/4p ci,- p -,y ,r—
Address: / 1a,�.+,1,- -- Vni 1a)e) .__. 14)
City/State/Zip: 1(?. �a j-y, , a1�i73 Phone#: 7)V. j2 V- a 3S
Are you au employer?Check the appropriate box: Type of project(required):
1.0 I am a employer with employees(full and/or part-time).* ' 7. 0 New construction
2.❑1 am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling
any capacity.[No workers'comp.insurance required.]
3. am a homeowner dour all work myself. t 9. ❑Demolition
g ys [No workers'comp.insurance required.]
10 ❑Building addition
.❑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 13.0 Roof repairs
These sub-contractors have employees and have workers'comp.insurance.:
6.0 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 the p,• . and ,. aloes of perjury that the information provided above is true and correct
Signature: — Date: ! ,/ `! t, j 9
Phone#: 77 0 ?f) Y._.2 5"'
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#:
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44 • PLOT PLAN
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FOR LOT #
Indicate location of garage or accessory building
Additions with dashed lines
Seelwlerage disposal (cesspool) ED
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Lot I Abuttor'
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/ Information
Supplied by
LARK NORTH POINT