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EXPRESS SHED PERMIT APPLICATI I' 'E C E I V E D
TOWN OF YARMOUTH
Yarmouth Building Department DEC 021p12 1146 Route 28
South Yarmouth, MA 02664 BUILDING DEPARTMENT
(508) 398-2231 Ext. 1261 By: 1
CONSTRUCTION ADDRESS:
OWN►:R:( ✓1 LAIC*(I' VC* i &kce...-- W, y&krMOcA,411 IP-OZ z21 —
NAME cd t44.t_t r��rjd' �6 I ,11,\!)C la ►ss__ TEL # (...I jam-/C/
CONTRACTOR: � �
NAME MAII.IN°ADI)I:1 tiS TE .# —
esidential Commercial Est.Cost of Construction$ I i C9 — .
Home Improvement Contractor Lic.# Construction Supervisor Lic.#
Workman'- ' i .. '-.:. . . . .,: (check one)
Fatni the homeowner I am the sole proprietor I have Worker's Compensation Insurance
Insurance Company Name: Worker's Comp. Policy#
SHED INFORMATION _ /
New Size L 7 x w 7 x H Corner Lot: Yes No v
Per Tones of Yarmouth ZoninL' Br-Law Sec 20.3.5 Note E:
.S'ide and rear yard setbacks for accessory buildings containing one hundred fifty(150)square fret or less and single storv,
shall he six (hi,teet in all districts. but in no case shall said accessorp buildings he built closer than twelve (l2)feel to am
other building on an adjacent parcel. All sheds are required to he located thirty(30)feel from any front lot line
Replace existing* Size L _x W x H T _
.The debris will he disposed of at:
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 answertst
will be just cause for denial or revocatio f my license and for rosecution under M.G.I..C'h,268.Section I.
Applicant I s Signature:____ \ r Date: Z /0I / Z
Owners Signature(or attachment) '6.1 Date: t 2—` of le L e�
Approved By:_ ._—
___ ADate: /S — /j --G't
13uildi IT ' or signee) EMAIL ADDRESS:
Zoning District:
Historical District: Yes / o Flood Plain Zone: Yes ✓"`'
Water Resource Protectio f7istrict: Within 100 ft.of Wetlands: ***
Yes v/No Yes ,„..--No
***Note:Conservation review required if within 100 ft.of Wetlands
3/22
' '"� The Commonwealth of Massachusetts
5dd.—._
epartment of Industrial Accidents
_%!� 1 Congress Street, Suite 100
Congress
_ ' 9 Boston, MA 02114-2017_
..'-Y ' _ www.mass.g
W� ov/dire
orkers' •
Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): CCD4"l -A-le Ste-
Address: I ik C e'-- R •
City/State/Zip: [Ai- yo-etlict.4 41 /vk, d�u �3 phone*: -Sr) d " (— `-1 3 �(c:f
Are you an employer?Check the appropriate box: I Type of rojeet (required):
1.❑I am a employer with employees(full and/or part-time).* 7. New construction
2.0 I am a sole proprietor or partnership and have no employees working for me in 8. E Remodeling
y-capacity.[No workers'comp.insurance required.)
' 3. I am a homeowner dome all work myself.[No workers'comp.insurance required.]I.
4. ❑ Demolition
4.0 i 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. Electrical repairs or additions
• proprietors with no employees.
- 12.7 Plumbing repairs or additions
5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.�1 Roof re airs
These sub-contractors have employees and have workers'comp.insurance.:
P,P:---
14. Other \�)'
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. `j� (I
152,§l(4),and we have no employees. [No workers'comp. insurance required.] t?"tl
'Any applicant that checks box R I 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 stab-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_
InsuranceCompany 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 S1,500.00
and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 3250.00 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: ) 2-/C>I7 2-2_Phone#: I7 c- �6 2-2 1. — -1 7 L-1 0
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 Depot Lucent 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person Phone#:
EL
PLOT PLAN
FOR LOT #
Additfor� W tested gams or sary building
Sewerage disposal (cam I~ `-_`—
Well isi
-ro 1 -) (1 6 07c)(/-\ g ek 1 ____. _
- - , _ _ I _
Abutters L, t�� Z'�=r 4 l�_ 1----> .................
Name 6� jz� b Abutter's
Lot# I
La
If this is a•
REAR YARD �-_ � Lot#
corner lot, If this is a
write in ��, �,- corner tot,
name of street •• 1; '-
write in
f name of street
‘li.3tri- i 5Vt2c,(1 11 e--
r= t; 1 14- i.._ _ LI '._ _ •
...J.�1 SIDE YARD (� - Z
75.
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SET aAca '
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R C-\. CC,— Oc---
t I i
(NAME OF STREET)._. 4 Irnformat:ca
Supplied by
Rubbermaid
7' x 7' STORAGE BUILDING
Assembly Instructions
COBERTIZO DE ALMACENAMENTO DE 213 X 218 cm
Instrucciones de armado
ABRI DE RANGEMENT 213 X 218 cm
Instructions d'assemblage
1 Q47
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1IIII1111111 I1 II IIIIIII►i
103 in = 1 —� '1 T261.62cm
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218.44 cm � I
84 in
\_/;..............„/ 213.36 cm
Thank you for purchasing this Rubbermaid°storage building.This dependable product was designed
to look great outdoors and keep your yard organized.We want your experience to be a good one.
Please read these instructions thoroughly before assembling the storage building.
Gracias por adquirir este cobertizo de almacenamiento Rubbermaid°.Este producto confiable ha sido
disenado para verse bien al aire libre y mantener su patio organizado.Queremos que tenga una buena experiencia.
Por favor lea atentamente esta instrucciones antes de ensamblar el cobertizo de almacenamiento.
Merci d'avoir achete cet abri de rangement RubbermaidmD.Ce produit fiable a ete concu pour avoir une belle
apparence a I'exterieur et vous aider a garder votre cour en ordre.Nous souhaitons que votre experience snit
agreable.Veuillez lire attentivement ces instructions avant de construire I'abri.
2053192
MORTGAGE INSPECTION PLAN 17-03429
LOCATION: 18 RACE ROAD BOSTON
CITY,STATE: WEST YARMOUTH,MA SURVEY, INC.
APPLICANT: WEST&JOHNSON
P.O.80X 290220
CERTIFIED TO: CIiARLESTOWN,MA 02129
DATE: 03-27-2017 T(617)242-1313;F(617)242-1616
991911490.STONSURVEYINC,COM .
i TOWN BROOK ROAD
47.Z4' 1316'
N
• LOT 28 I
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6,474 SF+/ t
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DECK j�ti. --- . - s,
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60.00'
RACE ROAD 1
SCALE:1"=20'
pI' RMINATION . `REFERENCES
Ag"nibigt'hd"l +lcaacylimasaffil Ae"'y riaPL 6' DEED:29021/132 N OF
lupej nentsonthispvpettyhd1inasamdedgrrtedas
ZONE: X PLAN:45✓17 ,,> `.
COMMUNITY PANEL No.25001C0567J GE
EFFECTIVE DATE: 7/17/2014 NOTE:To*wan rorara C scale thispla test bcprsmed
on legal sized pper(8-Y:14) COLliNS
i 'R� —'-'-' -n, ,r...b d on theme=tea.They the re see era 1,. unnr- Na.4s76s
:;.-dokcia=dug ordinance'a<eftect i the time of^' +ic'+o or ate wtetapt6nm violation adorcementaction wader ' 4,;r. �,
tvet r flak Vii,Chapter 40A,Section 7,sad that are no encroachments of major improvements across property Imes meept as
*awn and anted hereon. / mil s ''•
This is rota boundary or title insurance survey.This plan should not be used for construction,recording purposes or verification George C.Collins PLS
apraperty lines.
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