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Home My WebLink AboutBLD-23-000195 Yz &a.3-�tW 1 �' .� � O� Office Use Only OL- _ 1 RECEIVED MATTALF� CSC/ V•A�_--��-'�•-- Permit ��JJJ g JUL� � 2 _2 22 Amount , -'--- GA4 _ __ Permit expires 180 days fro m om BUILDING DEPARTMENT issue date EXPRESS SHED PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 1 dt cc 7"-- S.)-e-.4- 4 a OWNER: lb et /A"/ AlZ0V J UGt C�eSt�j Alit— 0267 NAME 11CC1�V ta/L((i1 0uj( PRESENT ADDRESS TEL. # CONTRACTOR: 4:77ALP_ y'��q-8 Cf f.� Q NAME MAILING ADDRESS C✓ TEL.# sidential ❑Commercial (�OD U Est.Cost of Construction S l Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workm ' mpensation ance: (check one) I am the homeowner I am the sole proprietor I have Worker's Compensation Insurance Insurance Company Name: Worker's Comp. Policy# SHED INFORMATION / New V Size L �C x W 0-- x H Corner Lot: Yes V No Per Town of Yarmouth Zoning By-Law Sec 203.5 Note E: Side and rear yard setbacks for accessory buildings containing one hundred re , t orshall be six (6)feet in all districts, but in no case shall said accessory buildings he built closer thanf tweingl lve (12)ess andfeet to any y other building on an adjacent parcel. All sheds are re uired to be located thin 30 eet om an row 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 ein contained are true and correct to the best of my knowledge and be of. 1 and stand that any false answer(s) will be just cause for denial ori vocation of i. and for prosecut', under M.G.L.Ch.268,Section I. Applicant's Signature: �� , / Date: Owners Signature(or attachment) / /r`L% AP -�Lt4a�� Date: Approved By: _r� ,— ^'� Building Official : igne- EMAIL ADDRESS: Date: C ITS r / oning 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 a= I Congress Street, Suite 100 —�•= Boston, MA 02114-2017 UP www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Lezibly Name (Business/Organization/Individual): ,,-(1/?._if S 6 -ej J',<j L Address: e. _ 0 2. ..06-4_ . U• /� City/State/Zip: [ :� Phone #: ,.�3 _ 7 -8 3 9 - 9/9 ? Are you an employer?Check the appropriate box: 1.— [am a employer with Type of project(required): er p y employees(full and/or part-time).* 2.a I am a sole proprietor or partnership and have no employees working for me in 2 n New construction any capacity. [No workers'comp. insurance required.) 8. Remodeling 3. I am a homeowner doing all work myself. [No workers'comp. insurance required.]; 9. C Demolition 4. I am a homeowner and will be hiring contractors to conduct all work on myroe I will 10 n Building addition — p . or are ensure that all contractors either have workers'compensation insurance sole proprietors with no employees. 11.— Electrical repairs or additions 12.C Plumbing repairs or additions 5.❑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.I 13.11 Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.n 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: 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 certiY fder the pai d penalties of per'ury that the information provided abo e is true'and correct. Signature. Phone#: -2 — Date: / Z 1 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Issuing Authority (circle one): Permit/License# 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: SHEDS LESS THAN 150 SQ. FT. SHALL. RE 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 11)dicate location Additions �r h Qz scary building — Sewerags ----- Sewerage dispel (oessponl) ____ I I _._. _ _ I (lat:................rt. ) I Abutter's 4 Name Lot# I j Abutter's I Name If this is a �j51427_ -47_4(j________ EAR YARDLot# corner lot, write inIf this is a name of street. ........l....ft. corner lot, write in name of street. i • 40. 1-1 #,' I v IT . S/DE YARD CX : 0 ._...FT_a.. C HOfISE SIDE YARD • • • ,,,i • • • 0..,c T BaIQC �J .• .• .ft. • -afu fnot................r ..ft. fxuntzoge) / N G,lc �2,� CC e SS iotz r v e t"-�i — \ / (NAME OF STREET) / `�"_ / Information stilPFlfed by