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Home My WebLink AboutBLD-23-005477 exe--/ r� 01YR b Office Use Only O i �`_6c) Permit# C'f6� ..ATTAC, •[3[_A 3 S ,00 �oqa,,;�.�, Amount e. Permit expires 180 days from issue date EXPRESS SHED PERMIT APPLICAT LD -a3-b0 5'-rn TOWN OF YARMOUTH ! R E_ C E I V E D Yarmouth Building Department 1146 Route 28 a APR 03 2023 South Yarmouth, MA 02664 1 (508) 398-2231 Ext. 1261 BUIL1fTCilsSPllTMENT `� CONSTRUCTION ADDRESS: �4 Pjti S ONr_ 1 By. I v OWNER: AM_ ..,SCA 0 ' C.944 EAtk'4S C `( • 1&` " 2-Za ' SIQc NAME PRESENT PRESENT ADDRESS TEL. # CONTRACTORt'I ({ ' "at Przylty,.. 5 Q59 Do 't+\c� 4 r Zc�(�LNAMEAILING ADDRESS TEL.[# Residential ❑Commercial Est.Cost of Construction$ L'[5 aco; Home Improvement Contractor Lic.# )'3a 93 5 Construction Supervisor Lic.# Cs-PA - c)Z 3 C'3(a Workman's Compensation Insurance: (check one) I am the homeowner I am the sole proprietor I have Worker's Compensation InsuranceInsurance Company Name: 'a....P4 e -Worker's Comp. Policy# C.- Lp(x .yaog5-7 •Qoaa A cr SHED INFORMATION , 1161( ape/oval v New X Size L IDt x W 8' x H /O' 1 .. Corner Lot: Yes No i//3/Z3 Per Town of Yarmouth Zoning By-Law Sec 203.5 Note E: '7 Side and rear yard setbacks for accessory buildings containing one hundred fifty(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 tn,LC\ ��a�(1 x H � *The debris will be disposed of at: (1ack `''.t,. A i_Z":-4 ;on 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. 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 I. Applicant's Signature: Date: wners Signature(or attachment) -�2 '"-` l� Date: J2cA 2 r--- G� Approved By: Date: Y / � � Building Officia r d ee) EMA DRESS: 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 3/22 111\11111 4,7:•• 4*.a ',•••••••. • • •:.•• • The Commonwealth of Massachusetts = = ' Department of Industrial Accidents _:6 i' � :,a �t 1 Congress Street,Salle 100 Titt:f Boston,MA 02114-2017 • • www.mass.gov/dia • Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE?ERN/LETTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): Mr, G z -r j 5+ " Boson We'pt ati i ors Address: City/State/Zip: ! rr& jhsfl1fl 5 Phone#: 505 '9 30 cg 8OO Are you on employer?Check the appropriate box: Type of project(required): I.0 I am a employer with employees(full and/or part-time)." 7. RiNew construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. El Remodeling any capacity.[No workers'comp.insurance required.) 3.0I am a homeowner doingall work myself. 9. Demolition y [No workers'comp,insurance required.]t 10 fl Building addition 4.01 am a homeowner and will be hiring contractors to conduct all work on my property. 1 will ensure that all contractors either have workers'compensation insurance or are sole I 1.0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.n I am a general contractor and I have hired the sub-contractors listed on the attached sheet, ]3. Roof repairs These sub-contractors have employees and have workers'comp.insurance.: L.I 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. 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 i.t providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Neo HCtrl t p.5l1 ire, Em plot it s Insurance Compa nri Policy#or Self-ins.Lic.#: ,—t Jigs 7 - cpOegaA Expiration Date: JU19 8 cx1,93 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 r t p 'n, an penalties of perjury that the information provided above is true and correct Signature: _/• Y Date: Phone#: {J -— 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#: • • SHEDS LESS THAN 150 SQ. FT. SHALL • RE PLACED A MINIMUM OF 30 FEET FROM THE FRONT LOT LINE AND A MINIMUM OF 6 FEET FROM SIDES AND PLOT PLAN REAR LOT LINES. FOR LOT # ) `1 rndicate location Additiorer with dasth or 3ory building Sewerage disposal (cesspool) Well xi 1 I - - I (lit I c f ft. rear) "1 I 0 ska-1iF,k IN c,, Pr 0Abutter's ( 5 i �R .� �.�Kx ti Name Abutter's Lot# 16 Name' Lot# c' If this is a REAR YARD corner lot, If this is a write in P.. .111",.ft. corner lot, name of street. write in name of street. 1 17®S�wer 1..--s y .a a 8 Lq SIDE YARD • _'3S��• HOUSE 24` C' SIDE YARD • •-a- 0 i • • • • • • • SET BACK I I • (lot 7 ft. frontage) • E\\y5 Cl'\1—• / (NAME OF STREET) Information • Supplied by a OFOTH TOWN F-RK 'i AP !---, 3:G,01:744,,L. TOWN OF YARMOUTH 1146 ROUTE 28, SOUTH YARMOUTH, MA 02664-4451 r� Telephone(508)398-2231 Ext. 1292-Fax(508)398-0836 OLD KING'S HIGHWAY HISTORIC DISTRICT COMMITTEE , , ,� APPLICATION FOR OLD KINGS HIGHWAY CERTIFICATE OF EXEMPTION Application is hereby made for the issuance of a Certificate of Exemption under Sections 6 and 7 of Chapter 470 of Acts of 1973, as amended, for the proposed work as described below and on plans, drawings, or photographs accompanying this application. Type or print legibly: /�� ( el' Address of proposed work: L-I 6t1,`z, r Map/Lot## PI ii `J Owner(s):,- r K.. 1 A . -- Phone#: I t ' Z 2_3 , 3 Q All applications must be submitted owner or accompanied by letter from owner approving submittal of application. Mailing addres . tU t c <. Year built: 2.6C' Email4 C' t_..,. 4.'0 referred notification method: t Phone X. Email Aaent/Contractor: i°(i.Q t.&.)t'+ -S Phone#:�'rt' , ZBoc Mailing Address:03 t Ac c (Rd - F ii l C.Xim t '1p %.)Q(.,4`C 5 Email: tANV J i ?i Y19�'�f ir, C'ovt"'-, Preferred notification method: Phone Y Email Description of Proposed Work(Additional pages may be attached if necessary):p x‘C\ :(M Cc j )C , .- 5 ,3( ACti ; , r^ " ' {y c C 15 € C ' .C...t- it:-`mil\ - Signed(Owner or agent): ` {ter yj.0 ?' .�' /�*� Date: 3/2 .G1„ , > Ovmer/contractor/agent is aware that a permit may be required from the Building Department.(Check other departments,also.) > This certificate is good for one year from approval date or upon date of expiration of Building Permit,whichever date shall be later. for Committee use only: Date: 1W3./23 / Approved Approved withtim — :7—Denied Amount Qk a) Reason for denial i Cash/CK#: C 6,1 "+ t 3 Ni?.-. Revd by. L .5' ?AtiMUU P' OW Is INgs tliGhwAy_,1 Date Signed:1174 Signed: c 1-.4 44re) APPLICATION#: V-e01 V52017