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Home My WebLink AboutBLD-23-005495 — > OVY9RF \/ ' , C ® O ce Use Only ,;' o - e� -23- 60-5 95 M,:,;,1 �,�,_ APR 04 2023 c ry I VtDa‘DEPARTI Permit expires 180 days from issue date EXPRESS SHED PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 CI ,/� �pppp �--,,(508) 398-2231 Ext. 1261 /1 CONSTRUCTION ADDRESS: I 1 II17RV fad "]EG Ii 5Ou P1 yl'1 gmIOV j O ZFj6 14 ' - OWNER: _fDU pRDo LOPCi 5I LA [LiRiv£ C • �LJ' c1�.. A 50U NAME P SENT ADDRESS TEL. # CONTRACTOR: NAME MAILING ADDRESS TEL.# esidential o Commercial Est.Cost of Construction$ 5 OCR,O'o Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) I am the homeowner 1 am the sole proprietor I have Worker's Compensation Insurance Insurance Company Name: Worker's Comp. Policy# SHED INFORMATION i/ew Size L _ x W . x H Corner Lot: Yes No t< Per Town of Yarmouth Zoning By-Law Sec 203.5 Note E: 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 x H *The debris will be disposed of at 0 G J` 1 Q F I P Lki 1 IJ& Q�E 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. A plicant's Signature: Date: 0 4 Owners Signature(or attachment) Date: w/Oil Io2O 23 - �i'9 .3 Approved By: Date: Building Official(or de ',n EMAIL ADDRESS: 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 _\ The Commonwealth of Massachusetts • ' = = Department of Industrial Accidents ff,• IEmmoil - 1 Congress Street, Suite 100 _►`= Boston, MA 02114-2017 .., �� www.mass.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): ,Capp Rsoo L. 51 L U19 A Li 41 uE C R1. R D• 614--°A ✓Address: 11 lA h R i j il R, � �t! ✓City/State/Zip:JaU y Phone #: 508 -36 0 -0l33 Are you an employer?Check the appropriate box: Type of project (required): l.E [am a employer with employees(full and/or part-time).* 7. _ New construction 2.E I am a sole proprietor or partnership and have no employees working for me in 8. El Remodeling an capacity. [No workers'comp. insurance required.] — ` 3. am a homeowner doing all work myself. [No workers'comp. insurance required.] 9. Demolition 4. I am a homeowner and will be hiring contractors to conduct all work on m YProe PnY I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.El 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.t 13. Roof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.7 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 c rtify under the pain and penalties perjury that the information provided above is true'and correct. Signature: Cra 49T. 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#: • 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 # Indicate location of gage or accessory building Additicer with dashed lines Sewerage disposal (cesspool) Well gg I I (lot ft. rear) { Abutter's I Name I Abutter's Lot# Name 6 Lot# 41, If this is a REAR YARD corner lot, If this is a write in ' co! treet r - . ... t$1 ,o 4. SIDE YARD • HOUSE SIDE YARD • • • •• • • • • SET BACX • • • ft. 1 1 40. (lot ft f rrntage) • �/ t-"32 LI J i / (NAME OF STREET) / \ Infiormatian \• Supplied by