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Home My WebLink Aboutbuildingn permit application O�Y4 1 4.. ! 's� RECEIVED omee use Only p y Permit# 2022 MA7u N '144 1 a ',OW4; AUG 3 Q Amount .ub BU I '44 UI � AIRT T Permit expires 1$0 days Brum By _�. ---tissue dale EXPRESS SHED PERMIT APPLICATIOO1 'g 3-00/124 TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: _.... . l ..l'e, rt. -1 e•t tJ , r 1 1i51? _k-I_.2_._. OWNER: (I ti • . NAMF. PRESL;N'I ADDR-SS FL. # CONTRACTOR' ..f,(")e(-&-;_ rte' 'ki a 'czf�, 141 el e" - -.ickSC -. `1s3NE MAIL.NU, ()DRESS eesidential Commercial Est.Cost of Construction$ -_- c 001) Home Improvement Contractor Lk.0 Construction Supervisor Lie.II _ __ Workman's Compensation insurance: (check one) V I am the homeowner I um the sok proprietor I have Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy# _-..__-. SHED INFORMATION New V Size L `y x W I D x H_ Corner Lot: Yes No (. Per Tower of Yarmouth Zonlua Br-Law Sec 203.5 Note E: Side and rear yard setbacks,for accessory buildings containing one hundred Jijty(150)square fret or less and single story, shall he sir(6)feet in all districts, but in no case shall said accessory buildings be built closer than twelve(12),/i et to any other building on an adjacent parcel. ell,shc is are required to he locale('thirty(30)/ el jroitt anr,front lot line Replace existing* Size L _ x IV x H *The debris will he disposed of at; Location of iFaciUn.4_.. 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(%) will be just cause for deni or revocation of my license and for prosecution under M.0 l..Ch,268.Section I• Applicant's Signature: o i rl _Alr- - /,/._ _ -__ - Date: Owners Signature(or attachment), - 1 42_1 .' Q /, •/ i; c�-c� .� Date: tomL_ U'. Approved Hy._._ Date: Building Official(Or designee) EMAIL At)DRESS. 1 Zoning District: Historical District: Yes No Flood Plain Zone: Yes No Water Resource Protection District: Within 10011.of Wetlands:*** Yes No Yes No ***Note:Conservation review required if within 100 R.of Wetlands 3/22 The Commonwealth of Massachusetts jt Department of Industrial Accidents r %!lr 1 Congress Street,Suite 100 Alriv Boston,MA 02114--2017 www rnass.gov/dig Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organizationllndividual): 00)Q; ( _ ds 1 tai) ( Address: 72 U OR the _ Ll) c216 • City/State/Zip: LVcA�vo f J fPhone#: Z l R Are you an employer?Check the appropriate box: Type of project(required): i.❑I am a employer with employees(full and/or part-time).* 7. 1RNew construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.[No workers'comp.insurance required.] 3" I am a homeowner doingall work 9. ❑Demolition ❑ myseI£[No workers'comp.insurance required] 4.2I 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 5.0 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? 1 Roof repairs 6.0 We are a corporation and its officers have exercised their right of tnuarption per MGL c 14.❑Other . 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. $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 ant 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 certify under the pains and/penalties of perjury that the information provided above is true and correct. Signature: ct)Q'�_7),9,- (cc ea ,/k 1, 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#: PLOT PLAN FORLOT # S Lidkje k Thd.,.... ...tic.Additions w h szsga °`� y buil x,� Sewerage lines - ------.__..�._____ Wel/ to pc�sal (cesspool) H9 Iht .' ��} ...........tit. I Abutter's -- Name Lot# Abutter's I 0 Name if this is a Lat# corner lot, REAR YA• write in .�� If this is a name of street, ftcorner lot, 5 D 3d write in _ t name of street. t � 'Q' t7• ti 7Ts 14.Q SIDE YARD : /6,3 Q : 1 i, • HOUSE SIDE YARD st�� ion;' 0_....lL.�_rrt> 7 : Oce--4' � - • • ' • 0 .171-1 ssT BAQCC • i • 1' \c-.) • V I • LX...- :e a-45;de ul i( - a , % , . 1 , (NAME OF STREET) e ,_"_7 / / t Informaticn Supplied by