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Permit expires 180 days from
B IL l issue date
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EXPRESS SHED PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664
f (508) 398-2231 Ext. 1261
/
CONSTRUCTION ADDRESS: S� r3c i�e—s SDug /4 r ierio a Iit ' / t q
OWNER(Pe_ f c e(c( k Q7g'8-c 196S.
NAME f ++__ PRESENTSE ADDRESS j TEL. # �y �7r
CONTRACTOR(..? (fQrea,r LD cJ-ci 32.6 g rim✓ 2� l 1 Sc 0nr.S 5�E'77,''Sd0
AME MAILING ADDRESS 4 TEL.#
esidential Commercial Est.Cost of Construction$ '3 q`j S. /
Home Improvement Contractor Lic.# / 3 2 9 3.E Construction Supervisor Lic.# G s f- 07 3 V.6 4
Workman's Compensation Insurance: (check one)
I am the homeowner a ' I am the sole proprietor// I have Worker's Compensation Insurance
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Insurance Company Name:AAA) I�crFlSk IC Cay [Oyer Worker's Comp. Policy# FCC 6 04 WO 0 96 7�i23 Pr
ID- Svrenct L_ty _
SHED INFORMATION
New Size L d x W E x H 9 01 Corner Lot: Yes No
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 he six (6)feet in all districts. but in no case shall said accessory buildings he built closer than twelve (1 2)feet to any
other building on an adjacent parcel. All sheds are required to he located thirty (30)feet front any front lot line
Replace existing* Size L x W x H
*The debris will be disposed of at:
Location of Facility
I declare under penalties of perjury that the statements herein contai d are true and correct to the best of my knowledge and belief. I enders nd that any false answer(s)
will be just cause for deni r revocation ofn c se and for p cution under M.G.L.Ch.268,Section I. n � q
Applicant's Signature: Date: / W
Owners Signature(or attachmen Date:
Approved By: Date: 0
Building Official esi EMAIL ADD S:
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
Geri is L/9 e Ve r 1 lO 1 . A&
S
" SHEDS LFSS THAN 150 SO F T SHALL_
ARE ['LAC'-r, A MINIMUM OF 30 FEET
FRnM THE Ht G;(:)N i LOT LINE AND G,
MINIMUM OF 6 FEET FROM SIDES AND
PLOT PLAN REAR LOT LINES.
FOR LOT #
Indicate location of garage or accessory building
Additicine with dashed lines
Sewerage dispoeai (cesspool) ®Nell of
--'
I I
_ — _.. I (lot rt. rear) I
4 -- •._ .
Abutter's
Lot# } Abutter's
1 I Name
Name
Lot#
If this is a REAR YARD
corner lot, top corner
If this is a
write in R. corner lot,
name of street. write in
I' _ name of street.
I C_C=I • . 4..›
r• Pk""4-14\
4
: SIDE YARD '
• HOUSE SIDE YARD •
•
•
•
•
•
• SET BACK .
ft.
}
I
(lot ft. fitntage)
/ /5— (R4keys L
(NAME OF STREET)
Information
•
Supplied by er crrts1v
The Commonwealth of Massachusetts
re Department of Industtial Accidents
1 Congress Street,Suite 100
;
Boston,/11,4 021144017
e Imo
www.inays.gov/dia
Workers Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY,
Aunlieant Information
Please Pript Legible
Name(Eusiness/OrgantzaonJTndivjjuaJy Lkt Cra-kAr. 9')e,c1nr N,4 C0 Ocia+I(,),C1
Address: 3Ei Civuetrn A%An ek
City/State/Zip: RoxtlykkArk Mk (NADLI5 Phone# & g 4,30- asoo
Are you sit employer?Cheek the appropriate box:
Type of project(required):
lam a employer with ),-• employees(full and/or part-nme) 7 Grgew construction
•
2 Di am a sole proprietor or partnership and have no employees working for me in & oRemodeling
any capacity [No workers'comp insurance required j
3 Or am a homeowner doing all work myself[No workers'comp insurance required J 9 Demolition
4 DI am a homeowner and will be hiring contractors to conduct all work on my property I will l0 Building addition
ensure that all contractors either have workers'compensation insurance or are sole I I.0 Electrical repairs or additions
proprietors with no employees
12.0 Plumbing repairs or additions
0 am a general contractor and I have hired the sub-contractors listed on the attached sheet
13.0 Roofrepairs
These suNeontractors have employees and have workers'comp insurance.
6 .Owe are a corporation and its officers have exercised their right of exemption per MGL c 14 CjOther
152,§I(4).and we have no employees [No workers'comp insurance required)
*My applicant that checks box Ill must also fill out the section below showing their workers'compensation policy information
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 cheek 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. Kj l'Ackvv,psry lvSirCj. LOVA L-1
Policy#or Self-ins.Lie # - C_XJ - (")(X)cA59-( 09-4114-Expiration Date 3,..4t..k aoaii
Job Site Address City/State/Zip.
Attach a copy of the workers'compensation policy declaration page(showing the pokey number and expiration dote).
Failure to secure coverage as required under MCiL 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 S250.00 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 a er tit penalties of perjury that the information provided above tru and correct
St i /.,
tur L Date, A
P *le#:
Official rise 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 or Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Thank you,
From: Melissa Childs melissa@pineharbor.com
Subject: Pine Harbor License Numbers
Date: Aug 9, 2023 at 12:04:23 PM
To: gerrish79@verizon.net
• r
Office of Consumer Affairs and ufiness Regulaticin
10 Park PJasra--Suite 5I70
Boston,IYISSS # • --etts 02116
Home Imgrovemt� -0!" '1 •+ Beaistratiori't .•
•
,� w Commonwealth of Massachusetts
Division of Occupational ticensure
�=LI t v Board of Budding tions and Standards
Mc(RATH POST&BEAM CO. " 1 cant 1 2"Faa "-
amity
DAMES Mt:GRATH iii C8FA-0738e5 per as:a r ar2024
259 IJEEM ANNE RD. .,
HARWMCH.NSA 020455. vi JAMES R '' ►.
Y^ eREWSTEtt '
a
Commissioner Bit uJ,s,
i(
THE COlvii*:)NVVEALTH OF'MASSACHUSETTS ,
Office Consumer A :. ,... :i • Flea
1OQOW.- -:- +E.: -S e 710
•�:,t• _'1 is
Horne 1 • ♦ _. : a :;r,•.,
v Type:
COrPOMOOO
( .,
,.. , . 132935
MCGRATH POST&�co. - W , > . to 4
DmfA PINE HARBOR WOOD PRODUCTS
259 0 JE4 i ANNE RD. .l �M'
HAR ICH,MA 02845 - _
INN Updates Address and Return Card.
1
i
TIE cot MO*vEALTI alr
Moe a Consumer 8 Business man Registration reed for indiv duail wee only before Mto
Hata: . ,, mtoiretion date. M found rotten to:
R z '' p... ()Mae of Consumer Af elmead Business Regulation
1000 Washington fittest•*thin ulo
�y�����y y S. 4 fi'? Boston,INA 021.1E
MC 3RATH PQ8T& +Pi i.4"aFY '
RANA PINE .a c' '-,
--,,,I .-.-,T.,.,,. . A.as' ,:'lior
J Man fl.MCGRATH: >r,
25a QUEEN ANNE RD.i;. ;..* a' ...4
t9ARWICH,MA 02848 %1/4_ ••L+,-. Y''.''w td, li, .
•
Melissa
Pine Harbor Wood Products
326 Yarmouth Road
Hyannis, MA 02601
508-771-5007
http://www.pineharbor.com
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