HomeMy WebLinkAboutBLD-23-001861T
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r ?�LL Permit#(0, [oclo6
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BUILDING DEPARTMENT Permit expires 180days from
BY -----
issue date
EXPRESS SHED PERMIT APPLICATION
TOWN OF YARMOUTH P 61 i a)
Yarmouth Building Department m 95
1146 Route 28
South Yarmouth, MA 02664 P d 02-a-a
(508) 398-2231 Ext. 1261 Cila/393-
CONSTRUCTION ADDRESS: \8 S t 1 \1 1- . - \ak, . QN mouk MI CA97
OWNER 1 v gcu t- Galt 0 1..;1 Slvek lecQ k),_)( s) .Q03 f 73 .?NAME PRESENT ADDRESS nn � /r' EE #
CONTRACTOR: .Inc Grc.\-ti ?OSY a- � v / r tilki-tN.C(/) 5a8—t( o
NAMEi
MAILING ADDRE.'SeXl� I �I h(le- KO,...,
TEL.#
Residential ❑Commercial Est Cost of Construction$ I a l dd0, 0
Home Improvement Contractor Lic.# 13 rn13 S Construction Supervisor Lie.#
Workman's Corn ensatio • ance: (check one)
I am the homeowner I am the sole proprietor . I have Worker's Compensation Insurance
Insurance Company Name: /Y o /kYI\s5\ re-- ..1.-wS c..... . rA. Worker's Comp.Policy# £ce _COO — G°95 0 %A
SHED INFORMATION
New Size L /.5 x W tO x H !/` ?k/a,/1 Corner Lot: Yes No )(
Per Town of Yarmouth Zorrin.Br-Law Sec 203.5 Note E: ,
.Side and rear yard,setbtrcks JOr accessory buildings containing one hundred fifty(150)square feel or less am!single .story,
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 are required to be located thirty(30)feet from any front 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 herein contai,ed 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 m ice c and for prti cution under M.G.L.Ch.268,Section 1.
Applicant's Signature: a _`f%
/ i 4 4,1 ����
Date: )—
Owners Signature(or attachment) , _ Av. i ,/.4 ,„1 Date: /23 /_)—
Approved By: -� / 2
Building Off;,''or; ignee) EMAIL -.a0 RESS: Date; �_
Zoning District:
Historical District: Yes No Flood Plain Zone: Yes No q / S-1-0/1 y i") J 1 k _.1
Water Resource Protection District: Within 100 ft.of Wetlands:*** ,q l „_g e /I e-/a r 67
Yes No Yes No /� (/t `�!
***Note:Conservation review required if within 100 ft.of Wetlands U i 8 7'7
3/22
The Commonwealth of Massachusetts
1 _ ; gri Department of Industrial Accidents
�; 1 Congress Street, Suite 100
Boston, MA 02114-2017
�, www.rnass.govldia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): (t ( C7-(9,1 , 14
Address: t q s)\ti p 1 x __
cl?City/State/Zip: L - )Ia fr c i ►'lo 7e% - i O 17o a9srq
Are you an employer?Check the appropriate box: Type of project(required):
IQ I am a employer with employees(full and/or part-time).* 7. C New construction
2.0 I am a sole proprietor or partnership and have no employees working for me in 8. Q Remodeling
any capacity.[No workers'comp.insurance required.)
` 3.Q 1 a homeowner doing all work myself.[No workers'comp.insurance required.]t
9. ❑Demolition
10 0 Building addition
4. I am a homeowner and will be hiring contractors to conduct all work on my property. I will
- nsure that all contractors either have workers'compensation insurance or are sole 11.Q Electrical repairs or additions
proprietors with no employees. ,
- 12.[(Plumbing repairs or additions
5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.Q Roof repairs
These sub-contractors have employees and have workers'comp.insurance.:
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.'Other 34.tk :
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.
Jncurance 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: Date:
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):
I. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
PLOT PLAN
FOR LOT , �AQ 13 Rp.GC� ,43
\ 3
Additions' with h arage orY build
Sewerage disP ]. (cesspool) EH
Well cg;
Itom.•..............tr. rear) I _G3
_... _.... ..... ..... I
51
-
Abutter's --...
Name
Lot# •2) � I
. - - Abutter's
1 _.,_t° lot# -s
i- Name
If this is a �I
corner lot, REAR YARD
: / '
. write in If this is a
name of street. ......••,....It. corner lot,
write in
E' ® name of street.
.
I
J 4
•
=DE YARD
SIDS YARD •
• HOME
a •
•
•
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ST BACK •
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7.
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(NAME OF STREET)
/ t Irmaticn
Supplied by
jw
ih' C-'antettonwealth of ltisAtte utsetti
4. Department col Industrial.4certientc
y 1 Congress Street.Suite 11111
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M tickers'C4,ttrpensution Insurance Affidavit: Buildersg untrttCtord?k:lectriciansiPlumber
TO BE FIt E►t 1All'll I lit ?Etat]I I INC.A I111Oik1 n.
,fi.ilpliestnt tntarmetinn Please Print Leethly
'saint't att :t7r s.14 Ste Rtenz tenre IMO iduul l...1J S1La:111- 'i • - _Eat'.'+_- ytki
ion
Atifiress:_ etriAlint,__Xtifid _ ....
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f tic ut propel-; : tat mtg.
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ram' - ZINO4 LtatSITUtitIt tt
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9 0 Flemuietiten
t Cj 1 var.1 naintc'c Janie an wattr-mrxit i Na ......kits ,trrg etawn11. . 4,4.11:-1 i'
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4 01 stir a net•tro>Ftlat tied Ls,tl Eve 141114 Coraasna t er,axa'+t, t all vt'•i ,4,rm n even,- 1%It'
I Asnn-1131:141 cnelt•a.tnn atthcr hat.Imarkett .,trrtttte:rra»em r-a- ,r.,<,r u,tr,a.'r II_❑1 leetrieal rerun%ter itrtdititltl,
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I.'. D Pittmonig rerai;•s yr addiUtm a
'n 1 alit li fatal ecraaeta en.i 4'1.::r 1.a`,t the subsca°taracInn 1rxs.t all*art.:clz:il 1111-x ! . taxr p iir
,1 ,
t hen 'ats.urlU,tt:tart has r .,ui t avr•.7+rkrts sump willa yn..1 t ice(
,` Du:.:,.s.C,caFypouitiun>.:t',- •, ,.. ,. '..;•,•: :1;.I.s 1M 't:r 14 ��J t._tla{y�f �.
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{ '!tmr:ex+7r.a,,rsaa as bra ttta affi a7'*t:n±aaang n^ ,_ 1..: ; _- , -11J 11101 1101 t/till,11111 rantractatt must warm;s raw=tttttv'.n kt+.facaflrt.,.;I
ix .^n*:t.;'a 11,31.chcai:et,,1..1,tired tom 1-I . , ,Its:. LL.,.,.mg Ott sty Jr 1L:tuts-=,ut t3`m.tut3..111,/lair Aheihr,eta„.I ttir•sn erns•t'lw
. tar.}1a..... If suis crntrs.-tnr-.ha:.c11,t t ta4Y+l4t1c thni iv,ri t-'cd::. l r itre s an?- .`._ ._,_Aar...
f ant tin t,nytlal'er;tuut a:providing ovurherl'cumprncatinu insurattee for ntr'employees. Melon.is the pulls y and jab site
is/ortnauon.
It14141:41e4e t.'t•'mpolly Narrtr NeiLdi 11 i(e__Ert)42k2iiti S (f iSL n(In t OtYl — —.—.
”oitey a tar salt-ms L e%a Et-i,).�( 7 ' cgoc,ag A b piralttun f'hile: Ju J 8.r•.)(}r
1„b Stu'.Addrt.;: _t uy:State.Ltn.
Attach a espy Of the Ruckert,'camlwnmutiun policy deek.atian page(showing the policy number and tws,piratiun dale).
Falsure tt•sacure t'derags. ratiJircd under MCI e 1 t_2, e.t is A -14te4 d sitsttdi.-ut punishable by a fine up trt f 1,CPCJ.tiIE
And ta= afllc-..eur tmprisonrnent,as wc11 as zii'ii p naiaee.,t'a tfae (..anti,,f n VI t1P Wt lth:(IR1)1`9 and i fate tag'up go 1250 Oft a
:hay against the s-io';:rrr. A ctIp) of th:-..taterncat may bc-le.mardc.i t;7 the(Hike ol Inv rstigatiun-vl rile 1)14 fir Incnr;ut.
do hereby t'rttr.' r t —ems-+
fs P ' ;an ,p penalties rrl p,perjury that du'informtttan l caridod ober,:it fru,'and evtrrell•
St¢ns7lrrt: Ctatt:
..ramie- !....,, —.------
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t;..fit-'nt er er..,.ili ;r,..,tit n rue ear this area,r e he a t►►nt,letcd hr rita or town°Jfrc'tul
ttk nr r chit: _ F ht'rtiL'i iCPnSC _ I
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Issuing Authority (circle()net:
1 1_ BaartA Of 11E111111 Z.Buiidirta Department 3.City)l'uµa Clerk 4.Lteciric tl Intipectot S.Plumbing;In+ttcune
b.Other
4'nuts;41 Pr►.Ua. PII4Oie 4:
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:_,,: ...r.,;;,3 1.720W-VM-ei,i24 cif
Consumer AffatrS and gus riessaeguiattor ,
I 0 Park Pilaa - Suite 5170
. .. Boston, Massao., -ctts 02.11 b
1111\
HC-111C an- provement >.,./..-ots tor Registra um-
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,---
MCGRATH POST & BEAM CO
JAMES MoGRATH
259 QUEEN ANNE RD
* __ ,-._ ... ,_
-IARWICH. MA 02645 ..„ , ,1-. sgir ..1" ^":
-„.... ,,,,... BREWS TER . t
Office of Consumer Affairs and Business Regulation
low Washington Street- Suite 710
Boston, Massachusetts 02118
Home IrnprovernePt Contractor Registration
typo Corporskon
Rerpst-aVon 132S,15
MCGRATH Pact7,1 &SEAM CO Expiration I ttalaC22
DitteA PINE HARBOR WOOD PPOOLICIS
259 QUEEN ANNE tie
HAflw''...-:- MA 02-145
Updabs Asktraaa and Rolum Cad-
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Fr PE:Carrorallop Worm the*Iptritiori dots. ,t tau rod return U
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i rwcris 10,300.,W7 IOW Woortiogtort Strom •Surto/JO
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