HomeMy WebLinkAboutBLD-22-005616 rn I(ci cf)) s 162
o�YaR,jo a !/ E 0 Office Use Only
OJk. 'H _- Permit# 661 gb
�` n TACM fiCi[ , LAIR&022 Amount Os.:�v aa..ae 9�(,
Permit expires 180 days from
BLDING DEPARTMENT issue date
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EXPRESS SHED PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261
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CONSTRUCTION ADDRESS: Iq
.J tl A (a.((Yleiex 1�1 y� (0 1` I h k) (< eJ, � rVer ✓nvtill'
OWNER: �tC�i �r%
NAM PRESS ADDRESS TE�
. #
CONTRACTOR: "Eke &✓bor tLted POdVC b 5-in 15O ) go 0
NAME MAILING ADDRESS TEL.#
Residential Commercial Est.Cost of Construction$ 170J 000 , 0 C-
Home Improvement Contractor Lic.#4_19=31106 13a 4 5 Construction Supervisor Lic.# 0/ 3 (J '
Workman's Compensation Insurance: (check one)
I am the homeowner 1 am the sole proprietor /have Worker's Compensation Insurance
Insurance Company Name: Worker's Comp. Policy#e�• (10 0 00(fC
Ir►�SUI a Co' SHED INFORMATION =7
``K 1 t 11 11112 on r ot: Yes No(
Per Town of Yarmouth Zoning Bp-Law Sec 203.5 Note E:
Side and rear yard setbacks fcrr accessory buildings containing one lrundrecl.lilir (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 he located thirty(30) feel from any front lot line p
I- ( Qh ce/va-h)f1 a /�/�9Wl
Replace existing* , Size L lol x W /0 x H // 7 .-6 -22
*The debris will be disposed()tat: Sra egt 0 t -DOC (-u't'a 1- Wes It! • On i
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:
•
Owners Signature(or attachment) L'L( Date: • _ l
Approved By: Date: 9'1 -4 I d am..
Building 0 (or d ignee) EMAIL ADDRESS:
Zoning District:
I listorical 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
0 0+ i O IC4-
The Commonwealth of Massachusetts .
,
~} _=, _ / Department of Industrial Accidents
_M 1 Congress Street, Suite 100
t =vF_�' Boston, MA 02114-2017
..''T 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): \iert( o tie (
ll 1 v\o G v LA e 4i/11
Address: Li (./ I L-uKtAlOetvtl< r' .
City/State/Zip: 0) (:4 Phone #: .S1) �-D 7 ' 5& 6
Are you an employer?Check the appropriate box: Type of project(required):
l.0 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. ❑ Remodeling
any capacity.[No workers'comp.insurance required.]
' 3.0 I am a homeowner doing all work myself. [No workers'comp.insurance required.] 9. C Demolition
10 [] Building addition
a homeowner and will be hiring contractors to conduct all work on my property. I will
re that all contractors either have workers'compensation insurance or are sole5k.nam
11.0 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.El Roof repairs
These sub-contractors have employees and have workers'comp.insurance.1
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.
1.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 tify under the pains a d penalties of perjury that the information provided above is true and correct.
VSignature: '. . 4k i . -yk� l
-t��,C �'� Date: - Lf_ e- 1--
Phone#: 52'8 a73 3 , 0 l
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
FOR LOT
t o Iaceticp of 5u.age ar aCIIII.Sory building
Addlidc ny with dashed lines
Sewerageimposed (cesspool.) EH
•
•
Well igt
- -- - I ( ................It. ) I
I
Abutter'sI
Name
Lot*
I Abutter's
•
1 �X Name
If this is a Lot it
If this is a
write in corner lot,
corner lot, k
name of street. 9"'' ft. L' write in
1' - • name of street.
I .0. .v.
50 B
13
•
SIDE YARD
sCI—
• HOUSE SIDE YARD
.ET
•
•
•
SET BACK
•
1
(lot ft. frontage)
4
/
r ' .&41,K. ,\) • Pd
(NAME OF STREET)
>
\/ ` InfnrmatIrn
/ `' Supplied by
\O Conservation Office
�� .AC Town of Yarmouth karantCa?varmouth.ma.us
�'v»�� ,4� Conservation Commission
:,. Building Permit Sign-off Application
TO BE FILLED OUT BY BUILDING PERMIT APPLICANT:
Building Site Location: tia 14;6h6,4 w S. 4 I 61001-i--
Map# u Lot(s)# t
Property Owner: JctCyL e hi e (CO' We lak I I Date filed: 6/— 6 �0.1,
*Applicant: JCtC7 ve I rl eCia r ne"'(Ii
Applicant Address: N a (° t+11k c K gd , S , YR-''rno
Email: }VI(fie liete Cax nJe l 1 C /n tt I,(01 phone: 50e . 7 3 3 66, I
-luiniber I/
Proposed Project Description: / S L. d i,f, i io X i y 5 Led D v r c II4 se d
2 place cx. / X ) ! d i
-row) pi-he 1-s.✓ r toad I)Y'dc t c'f51 rr" ic11) M4 II -- „, 17
ci'g '
Site Plan Title/Date: G/S /-/i 6- 0 c r c,i toe-f
8,q S Pi ve (
TO BE FILLED OUT BY CONSERVATION ADMINISTRATOR:
Does the proposed project require a permit? iVo 1A1-04' 3 ice`( /t ' l"J/
Refer to: SE83- or DOA permit
Comments from Conservation Commis: Approved Conditionally Approved Rejected
Conservation Commission Sign-off Signature: 16c'` - ''ti Date: 1,i. /6 /'2..2 ,
*TO APPLICANT:
All work-related debris shall be taken offsite or disposed in a legal upland location. At the end of each
day, the area shall be clean and no debris shall be in the Resource Area.
If work is permitted under an Order of Conditions, please arrange a pre-construction site visit with the
Conservation Administrator. At the time of site visit, the MassDEP File Number sign must be installed,
along with the erosion control/work-limit line. A copy of the Order of Conditions must remain on-site
during construction. Please refer to the Order of Conditions for further details.
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