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EXPRESS SHED PERMIT APPLICATI L
TOWN OF YARMOUTH
Yarmouth Building Department i `tr f ,
1146 Route 28 I _
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261
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CONSTRUCTION ADDRESS: '� I f)O-v- �l— L ZS Q��O�\It (AAA i 0, (o1
ASSESSOR'S INFORMATION:
Map: Parcel:
OWN YAK -€1 SZ Ly144.4ii ReQ j , 1 1 �, �(6 Z/0fo
NAME PRESENT ADDRESS TEL. # Email Address:
CONTRACTOR:
NAME MAILING ADDRESS TEL.# ,---J
/*� Email Address:
Reside tt' Commercial Est.Cost of Construction$ h V
Home Improvement Contractor Lic.# A) // Construction Supervisor Lic.#
Workman's Compensation Insurance: (check one)
I am the hotwner I am the sole proprietor I have Worker's Compensation Insurance
Insurance Company Name: Worker's Comp.Policy#
SHED INFORMATION
New ✓ Size L i t4 x W x H
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 k)/V4
*The debris will be disposed of at: !v /6-
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. understand that any false answer(s)
will be just cause for deni cation of my lice e or pr ution under M.G.L.Ch.268,Section 1. J
Applicant's Signature: Date: l I ( Zd
Owners Signat a(or ttachment) Q 'e Date: j �►�
Approved By: ' Date: '?' // • 2 "4''
B ding Official(or d
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
Department of Industrial Accidents
1 Congress Street, Suite 100
•
Boston, MA 02114-2017
. 5�•I www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information PIease Print Legibly
Name (Business/Organization/Individual): .vaitOCAVI - _t
Address: C (°av K. et
City/State/Zip: es I /Qv Phone #: lg 1 Co
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 doing all work myself. t 9. ❑ Demolition
y [No workers'comp. insurance required.]
4.0 I am a homeowner and will be hiring contractors to conduct all work on m YProPertY. 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.❑Plumbing repairs or additions
5.❑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.= 1 ❑Roof repairs
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 pai s a n 'es of perjury that the information provided a ve 's true and correct.
Signature: Date: v 11 2-6
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. BuiIding Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
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