The URL can be used to link to this page

Home My WebLink AboutBLD-23-002033, cci, -Itit loliewl- I f ii Office Use Only Permit# UM\ VC4,_\,,z4A4;‘ei, esEL4.41 Amount 3.5_ . Permit expires 180 days from issue date 6 Lip - 23 -,Odc nj EXPRESS SHED PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department — CEIVFD 1146 Route 28 South Yarmouth, MA 02664 OCT 172022 (508) 398-2231 Ext. 1261 BUILDING DEPAcifF0E-NT . CONSTRUCTION ADDRESS: / ‘ k ekt,„ c,_„ep kJ., s e,fit- C),,,e,Ac. b . .4„, OWNER: P iiii d- /1/0/11} .1,t4 eitf--c, - -- 31 - 362- 3.91/ NAME PRESENT ADDRESS TEL. # on, CONTRACTOR: NAME MAILING ADDRESS TEL.# 1 1 Residential Commercial Est.Cost of Construction$ I TOO.0e)Home Improvement Contractor Lic.# Construction Supervisor Lie.# 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 VSize L 6 x W cK x H I t 0 Corner Lot: Yes No Per Town of Yarmouth Zonink,Bv-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 stoly, shall be,six (6)feet in all districts, but in no case shall said accessory buildings be built closer than twelve (12).feet to any other building on an adjacent parcel. All sheds fire required to be located thirty(30) feet fi-om any from'lot line 0 io--) a-ppo Replace existing* dfr- Size L x IF x H he debris will be disposed of at: kA-k— id/062-- 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 re'ocatic 1 of my license and fo rosecution tinder M.G.L.Ch.268,Section I. Applicant's Signature Al/ Date: /42A/42L Owners Signature(or attachment Date: Approved By: Date: Building Official(or des e) EMAIL ADDRESS: Zoning District:_ Historical District: Yes No Flood Plain Zone: Yes No Water Resource Protection District: Within 100 It of Wetlands:*** Yes No Yes No ***Note:Conservation review required if within 100 It of Wetlands 3/22 The Commonwealth of Massachusetts =, � 1, Department oflndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 / www.nzass.gov/dia \Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): �A,' ! � M, yylc 2n Address: City/State/Zip: /4,-vt.,1t I�✓. : Phone #: '33 34 Sr - Are you an employer?Check the appropriate box: Type of project(required): I.❑I am a employer with employees(full and/or part-time).* 7. ivew construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 3. I am a homeowner doingall work myself. 9. ❑ Demolition ❑ y [No workers'comp.insurance required.]t 4.2am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 [j Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions • proprietors with no employees. , 12.EI Plumbing repairs or additions 5.0 1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. j ❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.1 6.0 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_ 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 pena 'es of perjury that the information provided above is true'and correct. Signature: ( Date: /0 / / Z Phone#: ;G ' 3. 'G/ 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. EIectrical Inspector 5. Plumbing Inspector 6,Other Contact Person: Phone#: PLOT PLAN FOR LOT if Z `/--- . Additions w d arage °r arY building Sewerage dizp1 (cessPoca) EHWell cgs I I ( ................f. ) I ._ I Abutter's �" -- ___ . Name Lot# Uzi�y� Abutter's If this is a �� n 'fir. �� to# zs` /3 corner lot, R YARD write in It this is a name of street. 1 f . corner lot, write in I name of street. +�i I • I : SIDE YARD q: . ' HODSE Siam YARD • • I SET BAQC : I' I I i / / (NAME OF STREET) / ` Infarmatim Supplied by c ... TOWN OF YARMOUTH 1146 ROUTE 28, SOUTH YARMOUTH, MA 02664-4451 Telephone(508)398-2231 Ext. 1292-Fax(508)398-0836 I___________ ... '' . r IV" 71 , ' ''' ' - 3' . KING'S HIGHWAY HISTORIC DISTRICT COMMITTEE , OCT 9 5 2022 APPLICATION FOR , ! CERTIFICATE OF EXEMPTION OLD KtNG'S HIGHWA y i Application is hereby made for the issuance of a Certificate of Exemption under Sections 6 and 7 of Chapter 470 of Acts of 1973, as amended, for the proposed work as described below and on plans, drawings, or photographs accompanying this application. Type or print legibly', , Address of proposed work: Jo k-et,t,C.0 vvi C t. il 6'.1-4 4<._ kolapfLot# I?/)10-- Owner(s): ,' / A /1/e,.<, / e Phone#: 3 - 36C-• '3 4rii All applications must be submitted by owner or accompanied by letter from owner approving submittal of application. Mailing address: / R-zr ok—e- A- Pi,/"rte./ P4 4 4/?5' 7 Year built: Email. iikic a.At. r ( L_ 6 /14(4,/ , C. ot-.--t Preferred notification method: ._-----Phone Email k Acient/COntractor P 1 'l/e gio, \v„r Phone#:cf)ir 9)0- 19 Mailing Address. ,:r 5- 9 a,...-a t- -. A kt , 12„,..1 Ar t..4,4f;,-j., . . . Email. Preferred notification method: Phone Email Description of Proposed Work(Additional panes may be attached if necessary): ckect• Signed(Owner or agent): , )14 , ..... Date: 7, ownerrcoritraciodagent is aware that a permit may be required from the Building Department (Check other departments,also.) > This certificate is good for one year from approval date or upon date of expiration of Building Permit.whichever date shall be later, For Committee use only: Date: I 015-1??.. I Approved Approved with cli. =:!!,k p"iit- - , led Amount 2 0.03 Reason for denial: I 11 (ICI V-'i /0'2? CasniCK#: (;)01q Rcvd by:_ 17 1....... i., , Date Signed: I C Signed: .5ea_ Aze 1,4/4. err? i APPLICATION# V5 2017