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EXPRESS SHED PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664
(5008) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS: 7L 1 �� I- S L.)9 N C 5 O• y dern i'l ok / lit 1�' Qo.)��e�l
ASSESSOR'S INFORMATION: /
Map: Parcel:
OWNER: kV/10 C(20 to N 17 Li L--es l—Mt✓c S y4IZb1u/77-1- 7(1/ a-1 vA S S t
rvrvj�AME J PRESENT ADDRESS TEL. #
CONTRACTOR: J 1j4tL4DO( \ ,ad ? d 1S c Se) G)crn Anne V.i �jtluELh.►rt l 508 ' 413 0 n?800
MAILINGNAME o� !
Residential ❑Commercial Est.Cost of Construction$ 0 8 (i a
Home Improvement Contractor Lic.# i 3 L 5 3 S Construction Supervisor Lic.# (- 7 3 8 C
Workman's Compensation Insurance: (check one)
I am the homeowner I am the sole proprietor 'I have Worker's Compensation Insurance
Insurance Company Name: Nat) lk(tmpshircimp}QHirc lfl3uranlf Co Worker's Comp.Policy# EcL000 AiOO( 57 -0018q •
SHED INFORMATION
New 1( Size L 1`t x W ) 0 x H !ICI. 1 l''Corner Lot: Yes 7 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* V Size L x W /0 x H
*The debris will be disposed of at: 1 IX i 01 c20l Qrai+ £.Lwfl ., 1 lL n n a j , 1 vi,
cation 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 1.
Applicant's Signature: Date: J/a 1,) 0
Owners Signature(or attachment) �—.-.Q Date: 3/10 1t
Approved By: Date: 3 \Cl d
Building Official(or designee) EMAIL 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
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FOR LOT 0 13 00
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Indicate location garage or accessory building Q
Additions with dashed lines to i JO
Si►r4 BA►? rerrageisidisposal (cesspool) eill
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I (lot....J.1j........ft. rear) J
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Name Lot a tA'H 17 I+t l"�0 W I' i Av j�(V-
Name
14.5 atuc Li/ sNor' I 1 Lot
Vic' ` PT I U x r y 'y I- REAR YARD
:f this is a
lot, - J If thib
corner :
trite in name /6 I A.•.ft.
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.. name of
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street.
: SIDE YARD •
SIDE YARD •
• HOUSE
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SET BACK ,Ll
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(lot 1/Y ft. )
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/ (NAME OF STREET)
/ 11\ Information
Supplied by
ARK NORTH POINT
The Commonwealth of Massachusetts
ph =
_ ice!l. Department of Industrial Accidents
�'_ 1 Congress Stree4 Suite 100
E _ —
__� = " 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):MC &(114h "t'us� t Qeam O "�' �j
( �
Address: Cj Owen Anne RoaA ��
City/State/Zip: Harwich AA 0.70,41 Phone#: SOS '130 02800
Are you as employer?Check the appropriate box: - Type f project(required):
LEI I am a employer with 60 employees(full and/or pari-time).* 7. `dNew construction
2.0I am a sole proprietor or partnership and have no employees working for melri 8. El Remodeling
any capacity.[No workers'comp.insurance required.]
3.01 am a homeowner doing all work myself.[No workers'comp.insurance required.]r
9.,.0 Demolition
4.01 am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
proprietors with no employees. 12.0 Plumbing repairs or additions
5.0tam a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0Roof 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: N[U/ HampShw E 1pIa3erS l romp:EN
Policy#or Self-ins. Lic. #:Fcc,-(pCiO-y( q57 (g A Expiration Date: Ir 1 (�1 a��)
Job Site Address: City/State/Zip: '1
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 certify u r e pains an e ' o erjury a information provided above is true and correct
Signature: Date:
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#: