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Home My WebLink AboutBLD-23-003192 ARC C W-1- )11g12J2 �: 4 Office Use Only � ,,4' Permit# e�s MATTACIY [SEf 09POR1iC04 C„ Amount 3.,an Permit expires 180 days from issue date EXPRESS SHED PERMIT APPLI �t;J�_ 3i CATION TOWN OF YARMOUTH RECEIVED Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 DEC 08 2022 (508) 398-2231 Ext. 1261 BUILDING DEPARTMENT CONSTRUCTION ADDRESS: 6 3. 5£,��t @,t� A b 1u � er:__ — OWNER: PI(,_( 0 6,f f'f gel ll`\S NAME PRESENT ADDRESS �� - TEL. # CONTRACTOR: NAME MAILING ADDRESS TEL.# Residential Commercial ❑ Est.Cost of Construction$ /0) 'TQO, 0 0 Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) D I am the homeowner I am the sole proprietor ❑ I have Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy# SHED INFORMATION e /7 jecnt-7 ii New Size L x W x H Corner Lot: YeseCPtil— t"'""� No Per Town of Yarmouth Zonin2 By-Law Sec 203.5 Note E: /t�1a7� 2 Side and rear yard setbacks 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 accessory buildings be built closer than twelve 12 parcel.All sheds are required to be located thirty ( )feet to any other building on an adjacent 9 (30)feet from any front lot line Replace existing* 7 Size L /0' x W I2t x H 1,11 *The debris will be disposed of at: ;+msk/_ t p -e( T 1/Lc3c) I..ucatsrn of Facility L 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.268.3ectioil I, Applicant's Signature: _ Date: Owners Signature(or attachment -- � Date: �- )-`Approved By: 2 ing icial(or designee) MAIL ADDRESS: Date: Zoning District: a Historical District: Yes No Flood Plain Zone: _i Yes No Ci Water Resource Protection District: Within 100 ft.of Wetlands: *** Yes �No Yes ***Note:Conservation review required if with;+n 100 ft.of We lands 3/22 _ • The Commonwealth of Massachusetts ' — Department of Industrial Accidents ail1= 1 Congress Street, Suite 100 "' _ f_ Boston, MA 02114-2017 17 5" Z�•`•y _ www.mass.gov/dia orkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly me (Business/Organization/Individual): L t 5 �� Address: 6 �.4v r > Irti _, City/State/Zip: 5 0 . Vl-ram•-,t, a T( Phone #: 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. E New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers'comp. insurance required.] 8. Remodeling 3.0 I am a homeowner doing all work myself. [No workers'comp. insurance required.]t 9. 2-Demolition 4. am a homeowner and will be hiring contractors to conduct all work on myroe I will 10 �] Building addition ''�� property.rh'• . ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. - 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 12.❑Plumbing repairs or additions These sub-contractors have employees and have workers'comp. insurance.t 13.El Roof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.El 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 pol cy 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 under the pains and penalties of perjury that the information provided above is tr e'and correct. Iianature: � Date: / Phone#: A . 3 5" Officialuse 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 6. Other Inspector Contact Person: Phone#: '- - i -.; SHEDS LESS THAN 150 SQ. FT. SHALL 13E PLACED A MINIMUM OF 30 FEET FROM THE FRONT LOT LINE AND A PLOT PLAN MINIMUM OF 6 FEET FROM SIDES AND REAR LOT LINES. FOR LOT t 3 84. Additions w h arage °r say building age disposal (cesspool) ED Well of I I (lOt f �P(,�0 Abutter's J � — I Name ��R��v Lot# ,r--- I Abutter's j Name If this is a Iti; REA� YA Lot# corner lot, `lay" write in If this is a name of street. ....... .••ft. corner lot, 22 hh4- r" •�, write in .� ( name of street. I ,5-.-.2. ' . .0. 1 tt; 4 . • SIDE Y• ARD SIDE YARD ' HOLD • • • • : • SET BACK • • • . 1 frontage) • \ / (NAME OF .. ,_4 STREET) / / \ xn£ cnattcn =uPPd by N )y Town of Yarmouth Conservation Office �M•T- M C';- Conservation Commission bdirienzotu�yarmouth.ma.us Building Permit Sign-off Application TO BE FILLED OUT BY BUILDING PERMIT APPLICANT: Building Site Location: I 3 �_...�, Map # 3-2, Lot(s) # 3, (, Property Owner: Al,ts,,.ti J`� A-A,4tp1 S Date filed: / )76/2.- 2- *Applicant: :.A-w..ti Applicant Address: <,(4 i✓ _ Email: ci2,jj'c:�3:� (d)i G::nrvtc:a s t,. ), / Please note:by`?Submitting this application,the applicant grants er�sion to the ConservatioOffi Telephone:to enter the cation — ct 4?�i to conduct a site visit(if needed). Proposed Project Description: Site Plan Title/Date: Cho P l c,ri CO ( L c)i. 8-Co, �Vt{ t� � u( t2lf122 TO BE FILLED OUT BY CONSERVATION ADMINISTRATOR: Does the proposed project require a permit? l ‘,., v«w Refer to: SE83- or DOA permit Comments from Conservation Commission: Approved ` (Conditionally Approved' Rejected SVvec\ my s� b'e S-r tulse t. c1^l � ci pee` fG {od4 tnG s t ravnctG 4la,�,CI S Conservation Commission Sign-off Signature: ( Date: �I 12 ,---- *TO APPLICANT: All work-related debris shall be taken offsite or disposed in a legal upland location. At the end of ea day, the area shall be clean and no debris shall be in the Resource Area. ch If work is permitted under an Order of Conditions, please Conservation Administrator. At the time of site visit, the MassDEP Fier Number sigon site visit with the n in along with the erosion control/work-limit line. A copy of the Order of Conditions must a bemain on-site during construction. Please refer to the Order of Conditions for further details.