HomeMy WebLinkAboutShed ApplicationEXPRESS SHED PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS:
OWNER:
NAME
CONTRACTOR:
NAME.
PRESENT ADDRESS TEL. #
MAILING ADDRESS TEL. #
11 Residential C Commercial Est. Cost of Construction $
Home Improvement Contractor Lie. # Construction Supervisor Lie. #
Workman's Compensation Insurance: (check one)
I am the homeowner I am the sole proprietor
Insurance Company Name:
New Size L x W x H
❑ I have Worker's Compensation Insurance
Worker's Comp, Policy#
SHED INFORMATION
Corner Lot: Yes No
Office Use Only
Permit#
Amount
Permit expires 180 days from
issue date
Per Town of Yarmouth Zoning By -Law See 203.5 Note E•
Side and rear yard setbacks for accessory buildings containing one hundredfifty (150) square feet or less and single story,
shall be six (6) feet in all districts, but in no case shall said accessory buildings be built closer than twelve (12) feet to any
other building on an adjacent parcel. All sheds are required to be located thirty (30) feet from any front lot line
Replace existing* Size L x W x H
*The debris will be disposed of at:
Location or 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:
Owners Signature (or attachment) Date:
Approved By: Date:
Building Official (or designee) EMAIL ADDRESS:
Zoning District:
Historical District: 11 Yes 0 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 a. of Wetlands
The Commonwealth of Massachusetts
Department of.IndustrialAccidents
o I Congress Street, Suite .100
Boston, MA 0-91.14-2017
Y
,, sw•` _ www-nzass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/plumbers.
TO BE FILED WITH THIS PERMITTING AUTHORITY.
Applicant Information Please Print Leg
Name (Business/Organization/Individual):
Address:
City/State/Zip:
Are you an employer? Check the appropriate box:
Phone #:
l.FJ I am a employer with employees (full and/or part-time).*
2.[-�- 1 am a sole proprietor or partnership and have no employees working for me in
any capacity. CNo workers' comp. insurance required.)
3.❑ I am a homeowner doing all work myself. [No workers' comp_ insurance required.] t
4. ❑ 1 am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers' compensation insurance or are sole
proprietors with no employees.
5.❑ 1 am a general contractor and I have hired the sub -contractors listed on the attached sheet.
These sub -contractors have employees and have workers' camp. insurance.t
6.R We are a corporation and its officers have exercised their right of exemption per MGL c.
152, § 1(4), and we have no employees. [No workers' comp. insurance required.]
Type of project (required):
7. ❑ New construction
$. Remodeling
9. ❑ Demolition
10 [] Building addition
11. Electrical repairs or additions
I2. Plumbing repairs or additions
13. Roof repairs
14. ❑ Other
-r.ny appncan< maL cnecrs oox Ft t must also till 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 certify under the pains and penalties of perjury that the information provided above is true' and correct
Signature: Date:
Phone 9:
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):
I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
PLOT PLAN
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name of street
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