HomeMy WebLinkAboutBld-20-4364 Office Use Only
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issue date
EXPRESS SHED PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS: (5 -I Ll rv\ e_ e-
ASSESSOR'S INFORMATION:
Map: 4 - Parcel: I(/
OWNER: 1 0e, `L5 Le51L2 V IVlv" t C-A-• '� O %- o1 - (5Z.'S
AME PRESENT ADDRESS TEL. #
CONTRACTOR: il-\`e_ kS•e--0 (—e-S I i:�I
NAME / MAILING ADDRESS TEL.#
7tesidential ❑Commercial Est.Cost of Construction$ gal)
T
Home Improvement Contractor Lic.# Construction Supervisor Lic.#
Workmap's Compensation Insurance: (check one)
VI am the homeowner I am the sole proprietor I have Worker's Compensation Insurance
Insurance Company Name: Worker's Comp.Policy#
l / SHED INFORMATION
New V Size L 4x W x H g Corner Lot:Yes No V
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: Pnl
Location of Facility
I declare under penalties of perjury at a statem Ms erein co tained 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 revo r fi of my li ns and fo r ecution under M.G.L.Ch.268,Section 1.
Applicant's Signature: (...l Date: 21 5 ) 2-'D
Owners Signature(or attachment) Date: 2-i S/ 27
Approved By: Date: �-'' ) - U)
Building Official(or designee) EMAIL ADDRESS:
_ma?, e� AGILELI=L'T�L. CO/'-i
Zoning District:
Historical District: Yes "No Flood Plain Zone: 1 : Yes LIcio
Water Resource Protection District: Within 100 ft.of Wetlands: ***
C. Yes No Yes No
***Note:Conservation review required if within 100 ft.of Wetlands
9/13
•
The Commonwealth of Massachusetts
Department of Industrial Accidents
• _',Flail- � 1 Congress Street, Suite 100
41 Fs .- Boston, MA 02114-2017
Sr•�,` www.mass.gov/dia
um
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): 4 Ek,k ley GeJX -e--
Address: (d F(Lt.in Lot.c,c' `
City/State/Zip: Ozst �64£ivwLci Phone #: 3V 2 f— (c L-r
020?
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. 0 Remodeling •
an capacity.[No workers'comp.insurance required.]
3. I am a homeowner doing all work myself. [No workers'comp. insurance required.]t 9. ❑ Demolition
4.0 I am a homeowner and will be hiring contractors to conduct all work on m YP roPrt3'•e 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.❑Plumbing repairs or additions
5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet.
These sub-contractors have employees and have workers'comp.insurance.t 13. Roof repairs
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other C/
152,§I(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.
tContractors 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.
•
1 do hereby certify under th pains an
d penalties of perjury that the information provided above is true and correct.
Signature: /
Date: B � � (Z i� 202.°
Phone#:
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#:
PLOT PLAN
o
FOR LOT #
Indicate location of garage or accessory building
Additions with dashed lines
Sewerage disposal (cesspool)
Well is
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Abutbar's
Name 6 `� Abutter'
Lot # I NI 6.S Name
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SIDE YARD
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(NAME OF STREET)
Information
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