HomeMy WebLinkAboutBld-20-004681 P' SHEDS LESS THAN 150 SO FT SHALL BF office Use Only
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a :._ P3 �-c i Permit expires ISO days from
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1 . PERMITAPPLICATION
TOWN OF YARMOU 1.II
Yarmouth uilding Department
1146 Route 28
/_� South Yarmouth. MA 02664
—7 0 (508) 39 j-22 31 Ext. 1261
CONSTRUCTION ADDRESS: J 7 / iC 4 3 0
ASSESSOR'S INFORMATION:
Map: / /._.._Parcel: 677 SP•0,A I "LI9'
OWH R: 6 L.I .E i3 E Higoildir 3?3 Aook o,r y(T"a+Q T S-6 F—3 to y— 7.6 ay
SL\ME PRESENT ADDRESS TEl.. „
CONTRACTOR: j' et,P/Ijn&
NAME MAILING ADDRESS TEL.i!
(Xesidential ❑Commercial Est.Cost ol'Construction$ 2 c._--/2. •)
Home Improvement Contractor Lie.A1 Construction Supervisor Lie.PI
Workman's Compensation Insurance: (check one)
-i 1 am the homeowner '% I am the sole proprietor : I have Worker's Compensation Insurance
Insurance Company Name: Worker's Comp.PoiieyP
SHED INFORMATION
New Size L 36 :x GT' I R x H _ Corner Lot: Yes do 'V .�.
3 R E a E "
Per Town of Yarmouth Zonin'Br-Law See 203.5 E: _.,...
Side and raar setbacks for accessory buildings Is than 150 square feet and siu lc st y. shaft ht ti 14 a iii,CA tr, kcts, )p i
in no case built closer thai: 12 feet to any other building.
!e
Replace existing* Size x 11 v H .
4k37- 6(41 ':. • ' '.-'` '
"the debris will be disposed ofat: J
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 anrwcr(s1
'aill be just cause tbr denial or revocation of no;license and for pro;ccution under yLG.I, Cit./_2�i3�3(�.,/SSee�c��ti_onn
Applicant's Signature: rylt a4- �� � eli _U tc: 0620
Owners Signature( ,ttachnrertX Date: .... . ao®Z d
Approved Dv: Date: Z'"-- ''
Ruildina Or al dcs•pcej EM ADDRESS:
Zoning District:
1
I lisioricial District: 't a -- No Flood Plain Zone: yes No
Water Resource Protection District: Within It)!!ft.of Wetlands: 1_,
Yes No i No
Y.
"ti`i<,te Con>ervation review required if'ithin 10(}f1.of\,Vetlanids i
o 1,
1 Q�
The Commonwealth of Massachusetts
1—.,,1011 i Department of Industrial Accidents
�`- _l I Congress Street, Suite 100
.4 } Boston, MA 02114-2017
www.mass.gov/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): If 0 A-o i7 L D
Address:
City/State/Zip: Phone 4:
Are you an employer?Check the appropriate box: Type of project(required):
I.❑lam a employer with employees(full and/or part-time).* 7. E New construction
2.E I am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling
an
9. ❑ Demolition capacity.[No workers'comp. insurance required.]
3. I am a homeowner doing all work myself [No workers'comp. insurance required.]t
4.E I am a homeowner and will be hiring contractors to conduct all work on my property. I will
10 E Building addition
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
50 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.El 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. '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$250.00 a
day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereb certify under the pains and enalties erjury that the infornzation pr ided above is true andi correct.
Signature a . o °ova
Phone#: 5-0, —310 tt --7-lo ay
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
1 y. •
•
PLOT PLAN
FOR LOT #
Indicate location of garage or accessory building
Additions with dashed lines
Sewerage disposal (cesspool) 69
Well
I I
_ _ _ _ I (lot IJ' 9 ft. rear) I
Abut tors 'CP,
Name IAbettor'
Lot # I Name
I Lot #
this a REAR YARD 3g
:arner lot, -. e 60 ft. If this
vrite in name corner
1f street. I Write 11
name of
a I a. other
ts
b street.
SIDE YARD
SIDE YARD .
a66
.
.
•
.
•
I .
I .
•
SET BACK :
•
,•
. /010,0 ft :
I 4
I
a
(lot../91Y/ ft frontage)
/ _______V-0-04--044 /2 -• YW7d.
/ (NAME OF STREET)
-411\ Information
Supplied by
IARK NORTH POINT
opecicaro-
.
(1:-YINTOWN OF YARMOUTH ftecEIVeD
1146 ROUTE 28, SOUTH YARMOUTH,MA 02664-4451 2O2O
Telephone(508)398-2231 Ext. 1292—Fax(508)398-0836 FEB 11
RE$ E11, G'S HIGHWAY HISTORIC DISTRICT COMMITT E ,K��"�O1��
FEB 'I 3 2020 APPUCATION FOR
CERTIFICATE OF EXEMPTION
TOWN CLER
ApplicaMiltWitfyikkjt dip issuance of a Certificate of Exemption under Sections 6 and 7 of Chapter 470 of
Acts of 1973, as amended, or' % proposed work as described below and on plans, drawings, or photographs
accompanying this application.
Type or taint ably: ) j \ -poi} J i l`'(
Address of proposed work: "1 o L o O KO v�� L Y i 3 S / Map/Lot#
J
Owner(s): E t, shoe ra A D'So 1T /41 w Pilinc OTT Phone#: so 1-3 Gy- 6 2 y
All applications must be submitted by owner or accompanied by letter from owner approving submittal of application.
Mailing address: 3 8 4 00 Kd if Ro y'Po R i Year built: G A I T
Email: Preferred notification method: /i"� Phone Email
Aoent/Contractor: SEC,i Phone#: 6-ea-3 e 4- ? .(r
Mailing Address: a 7 It oC K o V T
Email: Preferred notification method: " Phone Email
Description of Proposed Work(Additional Dams may be attached if necessary):
(1r ( 2 'Ca+� 6. 14 o.4,ii 3I1.w2;o .v
Signed(Owner or agent): •1� Date: /�
�
> Owner/contractor is aware that a permit may be required from the Building Department.(Check other departments,also.)
• This certificate is good for one year from approval date or upon date of expiration of Building Permit,whichever date shall be later.
For Committee use oniv:
Date: a- t I- C /Approved Approved with changes Denied
Amount a 6 Reason for denial: APPROVED
cash/: a9 9
,l� FEB 1 3 2020
Rcvd by: t
YARMOUTH
QJ(MING'S tJICUWAY
Date Signed:2/!3l2e2o Signed: 67
APPLICATION#:
VS 2017