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BUILDING DEPARTMENT Permit expires 180 days from
Rv _ issue date
EXPRESS SHED PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28 /MC(jl
South Yarmouth, MA 02664
(508)
398-2231 Ext. 1261 ,1�
CONSTRUCTION ADDRESS: L1 0 OC )(j00c 01.(kie Sou `-- 'V OU}.i 0 3..(gGt-( /rt rc
OWNER: raxn&m/1 OA a Vll SCE - aci 7 11
NAME PRESENT ADDRESS TEL. #
CONTRACTOR:
NAME MAILING ADDRESS TEL.#
Vesidential l 0 Commercial Est.Cost of Construction$ AN)
Home Improvement Contractor Lic.# Construction Supervisor Lic.#
Workman's Compensation Insurance: (check one)
I am the homeowner 1 am the sole proprietor I have Worker's Compensation Insurance
Insurance Company Name: Worker's Comp. Policy#
/ SHED INFORMATION
New Size Unit,- x W ( 0 x H Corner Lot: Yes No V
Per Town of Yarmouth Zonin'By-Law Sec 203.5 Note E:
,Side and rear yard setbac ks for accessory buildings containing one hundred fifty (150) square feet or less and,single,story,
shall be six (6)feet in all districts, but in no case shall said access'ol'v buildings he built closer than twelve (12) feet to any
other building on an adjacent parcel. All sheds are required to he located thirty(30)feet front cult]ront 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 per y 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 o vocatio of my license al for prosecution under M.G.L.Ch.268,Section I.Applicant's Signature: Date: r T�
/7-7102a
Owners Signatur ( attachment) Date:
Approved By: Date:
Building Official(or designee) AIL 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
_. - /, Department of Industrial Accidents
_��= 1 Congress Street, Suite 100
,\_a �= Boston, MA 02114-2017
,. _ 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):
Address: Li 0 vc�( o d O C7�t;J�
City/State/Zip:co,L u)„v,ocJ4 M H do GGy Phone #: S OZ ra cio2---7 en
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. 1] New construction
2.0 I am a sole proprietor or partnership and have no employees working for in
any capacity.[No workers'comp. insurance required.] 8. Remodeling
3I am a homeowner doing all work myself. [No workers'comp. insurance required.]; 9. ❑ Demolition
4.❑ ProPrtY I am a homeowner and will be hiring contractors to conduct all work on mye I will 10 ❑ Building addition
ensure that all contractors either have workers'compensation insurance or are sole
proprietors with no employees. 11.[] Electrical repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 12.El Plumbing repairs or additions
These sub-contractors have employees and have workers'comp. insurance.t 13• Roof repairs
6.E 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.
T Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors 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 certi and the pains and penalties of perjury that the information provided a ove i true and correct.
Signature: .
Date: / 1 a z
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#:
.
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corner lot, REAR YARD
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name of street.
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