HomeMy WebLinkAboutBLD-23--001079 pi 1)50/2 2_
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Office Use Only
" Permit# ca/Amount —�
Permit expires 180 days from
issue date
EXPRESS SHED PERMIT APPLICATIOl
TOWN OF YARMOUTH RECEIVED
Yarmouth Building Department •.-
1146 Route 28 2 6 2022
South Yarmouth, MA 02664 AUG
(508) 398-2231 Ext. 1261
` BUILDING DEPARTMENT
CONSTRUCTION ADDRESS: Z ?:,.���. 1. 1 BY
OWNER: V,\,'QX).✓' Le_; ‘,*( 2-8"1;l CA-k- IC. To CJ -3 J Cka
NAME PRESENT ADDRESS TEL. #
CONTRACTOR:
NAME MAILING ADDRESS TEL.#
Residential D Commercial Est.Cost of Construction$ (OS-CDO . 00
Home Improvement Contractor Lie.# �,....4 Construction Supervisor Lie.# C. ' 05 316/
Workman's Compensation Insurance: (check one)
✓-1 am the homeowner Lam the sole proprietor I insurance
Insurance Company Name: Worker's Comp. Policy#
f r� SHED INFORMATION
New Size Lt'""xx W ` x H � `� Corner Lot: Yes No
Per Town of Yarmouth Zoning' Bp-Law Sec 203.5 Note E:
Side and rear yard setbacks fir acce.s.sot.y buildings containing one lu ndre d fi fty (150) square,feet or less and.single
shall he six (6) feet in all districts, hut in no case shall.said accessory huildings he built closer than twelve (1)feet to any
other building on an adjacent parcel. All sheds arc'required to be located thirty (30) feet front anyjront lot Intel"-
Replace existing* 4- Size L- " x x
*The debris will be disposed of at: lq E -5 Lo S\- 0 Z.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
ooff� e l Date: AO,
my license and for prosecution under M.G.L.Ch.268.Section I.Applicant's Signature:
Date: It 1/2�
Owners Signature(or attachment) f
Approved By: / Date:
Building Official(or designee) 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
ral Department of Industrial Accidents
•_��': l_ 1 Congress Street, Suite 100
_r�= Boston, MA 02114-2017
_ www.mass.;ov/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): h -L S
Address: `
City/State/Zip: We4 tly\m„Sk\-- VAl Phone #: C -32C2
Are you an employer?Check the appropriate box: • Type of project(required):
1.0 I am a employer with employees(full and/or part-time).* 7. ❑ New construction
2.1:1 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. ❑ Demolition
364.am a homeowner doing all work myself. [No workers'comp. insurance required.]t
10 ❑ Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.❑ 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. 13.C Roof repairs
These sub-contractors have employees and have workers'comp. insurance.]
14
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c.
,Other 5l,-{(z.
152,§I(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:
f;
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 under tlz rains and penalties of perjury that the information provided above is true'and correct.
•
►�! j 13 2Z
Signature: Date:
Phone#: 506 ` 3 Z(ci (p
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#:
PLOT PLAN
FOR LOT
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ithes
Sewerage disposal (cesspool)
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Lot# taiU Abutter's
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Name jdo
` ,� Lot#
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corner lot, Cy t REAR YARD
l? If this is a
write in /
` ill comer lot,
name of street. ,' "�� �3 • write in
' name of street.
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