HomeMy WebLinkAboutBSHD-23-44 ' -''''\`?.•\.A.*4
t \ RECEIVED Use /�C
tOleit
'S �} l Cat 2112 amount 3s.(5-v
L.. ► Permit expires 180 days from
BUILDING DEPARTMENT issue date
By:
EXPRESS SHED PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route-28
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS: 2( yeo Al an lY Wes-4 _et.r_
OWNER: __ale_ H (1 al )!eoma ,br _Jill 5D C2 sc(-S
NAME PRESENT ADDRESS TEL. #
)(CONTRAC FOR:
NAME MAILING ADDRESS TEL.#
wi Residential 0 Commercial Est.Cost of Construction$ 6 7 ou •
Home Improvement Contractor Lir.#T` Construction Supervisor Lic.#
Workman's Compensation Insurance: (check one)
I am the homeowner I the sole proprietor I have Worker's Compensation Insurance
Insurance Company Name: �..__ Worker's Comp. Policy
SHED INFORMATION
L
New X. Size L I 1 x W 10 x H Corner Lot: Yes No
Per Town of Yarmouth ZorrinM Br-Law See 203.5 Note E:
Side and rear ord setbac ks,fOr at cessotv buildings containing one hundred fifty(150) square feet Or/.C.s and.single scot:v,
shall he AiT t61,/i:et in all districts, but in no case shall said acec7s.sory buildings he built closer-dram twelve 112l It't't to tart•
other building on an adjacent parcel. :ill.sheds are required to be located thirty(JO) lee?'i front ant lot line
Replace existing* Size L x IF x H
*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 answctts)
will be,Just cause for denial or rev a.on of my license a for prosecution under M.G I..Ch.268.Section I.
Applicant's Signature: L Date: 6) /�l-J 3
Owners Signature(or attac meat) Bate:
A
72-.
Approved By O .� / �_
Date
Building Offi-. I(or lane EMAIL RESS.�
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
/>'1 r kC der)11Pkl e Cancels-/'- he -
The Commonwealth of Massachusetts
Ps Department of Industrial Accidents
•
1 Congress Street, Suite 100
Boston, MA 02114-2017
IMPwww.mass.gov/dia
\Vol-kers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): � I ( �. F(Q ((
)e Address: \/‹..
x City/State/Zip: lees-� e l m e� 1�IA �� Phone #: 5 g dto • 5`7 `-f- 8
Are you an employer?Check the appropriate box:
Type of project(required):
LE 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
y capacity.[No workers'comp.insurance required.]
3.��1 I am a homeowner doing all work myself. t 9. ❑ Demolition
y [No workers'comp. insurance required.)
am a homeowner and will be hiring contractors to conduct all work on myroe I will 10 Building❑ addition
P property.
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
5.0 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.: 13.❑Roof repairs
6.❑We are a corporation and its officers have exercised their right of exemption per MGL a 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.
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 cer fy nder the pai and penalties of perjury that the information provided above is true and correct.
(Signature: Date: ? 1,33
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#:
PLOT PLAN
FOR LOT 3
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name of street. ........i.•..ft. corner iot,
write in
name of street.
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HOMESIDE YARD
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