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Home My WebLink AboutBSHD-23-48 `4'V1.'yARN,F C �/'� \p5 Office Use Only l; 1c REGIv � ® OI. A .P-i4, Permit# - 0 nAiE_/ , �q .. -"� LAue 11 2023 Amount� � r Permit expires 180 days from BUIL . ENT issue date Tritc_v By: EXPRESS SHED PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department SSR b -Z3,__Lf. 1146 Route 28 �I t South Yarmouth, MA 02664 `'` (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: .3 C'(2 S \\G - v c - N OWNER: N C(k, ;-,� t.-� �' NAME PRESENT ADDRES TEL. # L� CONTRACTOR: NAME MAILING ADDRESS TEL.# 0/Residential Commercial f6� DO D Est.Cost of Construction$ , Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) VI am the homeowner I am the sole proprietor I have Worker's Compensation Insurance Insurance Company Name: Worker's Comp. Policy# SHED INFORMATION New Size L x W x H Corner Lot: Yes V No Per Town of Yarmouth ZortinL Br-Law Sec 203.5 Note E: Side and rear yard setbacks fin- 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 t twelve (1 2)feet to any other building on an adjacent parcel. All sheds are required to he located thirty(30)Jeet front anvfront lot line Replace existing* V Size L x W Ni) x H_S___ vs‘ i *The debris will be 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 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: S /, 614.../f Date: S,,u`7S Owners Signature(or attachment) J Date: 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 j� j'�r 3/22 "Pr 11 1 if V3 ,r5 - •'ti� IIii we- A. \ The Commonwealth of Massachusetts 14=., Department of Industrial Accidents =��_c 1 Congress Street, Suite 100 1'—/MM Boston, MA 02114-2017 'N :.5'y`,y 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): V.sciA\--1\ Address: C cu.-3\ ' , City/State/Zip: S ,�-,r\,,; \� (D Phone #: ` - —2\Z-L - Are you an employer?Check the appropriate box: Type of project(required): I.❑I am a employer with employees(full and/or part-time).* — 2.0 I am a sole proprietor or partnership and have no employees working for me in 7. — New construction any capacity. [No workers'comp. insurance required.] 8. Remodeling 3.Rram a homeowner doing all work myself. [No workers'comp. insurance required.]t 9. [1] Demolition 4.0 I am a homeowner and will be hiring contractors to conduct all work on myroe I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employees. 11.0 Electrical repairs or additions 5.E 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 I •❑Roof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other. 152,§I(4),and we have no employees. �t' [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 certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: ��A41 Date: 4V/(4 2- Phone#: LI -7 2 -C \ 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#: r PLOT PLAN FOR LOT f D-KW2te location Additions with gmasse °TY building Seww� dismal (cesspool) ES' off I I ........... — ` I (lpt................it. I Abutter's Q ` 1 . Name Lot# ! Abutter's Name If this is a Lot# corner lot, REAR YARD write in If this is a name of street. ........,•"*It' corner 62 lot, write in name of street. 'i i I 4 SIDS YARD SZ! sa——r--ETA. 0 HOUSE DR YARD • r� : SET BACK : .I . I • (lot.. ...............ft. frontage) ‘ / Q. \ 1 / \ (NAME OF STREET) / \ nrntatian Supplies by