BLD-23-002792 rA. aul
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Office Use Only
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�• 4'br.;t f,} - Amount 3 , i U
Permit expires 180 days from
issue date
EXPRESS SHED PERMIT APPLICATI 0
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TOWN OF YARMOUTH RECEIVED
Yarmouth Building Department -_-..____,,.. ..„__._.___
1146 Route 28 Fli0V 18 2022
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261 _
BUILDING DEPARTMENT
CONSTRUCTION ADDRESS: 16 flil/pp iyf4 Rd, By:
OWNER: liEv</v Rfilco ti► gro 0 a_ ii-oparAt mit .SOY 3 r!7-77`'3
NAME PRESENT ADDRESS TEL
TEL #
CONTRACTOR:
NAME MAILING ADDRESS TEL #
Residential D Commercial Est.Cost of Construction$ 6,5"-eb. 0 0
Home Improvement Contractor Lic.# Construction Supervisor Lic.#
Workman's Compensation Insurance: (check one)
I am the homeowner I am the sole proprietor I have Worker's Compensation Insurance
Insurance Company Name: Worker's Comp.Policy#
SHED INFORMATION
p f Ac New 7 Size L /1{ x W to x H O G Corner Lot: Yes f�/
No
Per Town of Yarmouth Z,orrin' By-Guar Sec 20?.5!Vote L
,S'irle wal rear t mf,;(4hurks /ru,are es sr)til hrrilrlingA redninirr:j fin hundred fi/Ir t 150r sgliurr leei or lc..s and,single strv,
Shull he.siv(h)feet in ctil i/ihtrirh, hitt ill ii1.r[L4•C Shill'.suitl uc•c•,rssort buildings he hull!'e/u.ct'r than Ill.clue (/?)feet!c1 any
clnccr building oil tilt uel/urrtri PtII-VI _III s/rat/S ,UV I /ifirollo hc.Inc tLtt<l,t/rirtrt3t1)Jt(i jrant wi_jrom/ t/iife
Replace existing* Size L x W x H #Q
*The debris will be disposed of at _4(0 nE f
Location of Facility
I declare under penalties of perjury statements herein contained are true and correct to the best of my knowledge and belief I understand that any false answers)
will be just cause for denial or r of my li and f ecution under M.G.L.C.h.2f,8,Section I.
Applicant's Signature: Date: l7j®a+
Owners Signature(or attachment) A �jy-V Date: 10//s sq?--
Approved By; Date:
Building Official for deli' EM. L ADDRESS: /
Zoning District
Historical District: Yes No Flood Plain Zone: Yes No
Water Resource Protection District: Within It*ft.of Wetlands:***
Yes No Yes No
***Note:Conservation review required if within 100 ft.of Wetlands
3/22
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-� The Commonwealth ofMassachusettr
•
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ri Department oflndustrialAccidents
ra-` �T
,1= a 1 Congress Street,Suite 100
'. '* Boston,MA 02114-2017
~ wow mhos-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): pI)iA/ (3,4/6A
Address: /6 AZNa/',A1,4 re/
City/State/Zip:gl, // j?/1110U1/'f- Phone#: Sid ' ?7 7-77 9 3
Are you an employer?Check the appropriate box Type of project(required):
1.O I am a employer with employees(full andfor 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]
9
` 3x am a homeowner doing all work myself.[No workers'romp.insurance required]t 1 CI D mo ldin icon
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 0❑Building addition
ensure that all contractors either have workers'compensation insurance or are sale 11.0 Electrical repairs or additions
proprietors with no employees.
-
12.0 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.*
13.Q Roof repairs
6.Q We are a corporation and as 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 erititim have
employees. If the sub-contractors have employees,they must provide their workers'comp_policy mbar.
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
ancUor 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 certifya pains and penalti of pe 'toy that the information provided above is true and correct
Signature: z‘/
_,G 3, • Date: //�l�c��
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
r Contact Person: Phone#:
; -,
PLOT PLAN
FOR LOT #
•
Thdicat a 130stial of garage or accessory building
Additions. with dashed lines
Sewerage disposal. (cesspool) 69 '"________.�
Well of
I
_ ._._ (lit. ft. rear) t
.0. tram �.�.
Abutter'sI
Name Abutter's
Lot# I �� Name
Lot#
if this is a
corner lot,
Rtt � It this is a
write in jo k corner lot,
name of street. j �_ write in
# �' name of street.
.I )341f- i
13
4 t
SIDS YARD
y ROUSESIDE YARD
:
•
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`X SET BACK
1
1
-a
(. .� ' gieVA ft. stage)
•
1 l (NAME OF STREET)
/ Informa�,
/ _ supplied by