HomeMy WebLinkAboutBLD-23-000942 -;.. ,sue=-a¢
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r 9� CG W I I t L- re vi Office Use Only
RECEIVED
O '.o.., I Permit# 04-vie
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S»� �rAC�„sEI Amount "
t AUG 1 2022
Permit expires 180 days from
---
BUILDING DEPARTMENT issue date
EXPRESS SHE BY: IT APPLICATIONr�3—pbday�
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS: j/ (/c1�'j j
, ,e_af-
OWNER: ��( ± 1 ' -Oyi'l i ha"( F.5 N4.- 6 t'7— 7O 3 .._S J l
NAME PRESENT ADDRESS TEL #
CONTRACTOR: Px-frx>lidt..cciac O. eo x ?W y—t -7 7y--3s f Sc
NAME MAILING ADDRESS TEL.#
f.,s sidential Commercial Est.Cost of Construction$ / � r
0
Home Improvement Contractor Lie.# Construction Supervisor Lie.#
Workman's Compensation Insurance: (check one)
xam 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 f x W /0 x H 7 Corner Lot: Yes No
Per Town of Yarmouth Zoning Bv-Law Sec 203.5 Note E:
Side and rear yard setbacks for accessory buildings containing one hundred f fty(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)feet to any
other building on an adjacent parcel. All sheds are required to be located thirty(30)feetfronz any front lot line
Replace existing* Size x W x H
*The debris will be disposed of at: l
Location of Facility
I declare under penalties of perjury the statements herein co ained 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 rev on o"my Ii and f^ ^ i secution under M.G.L.Ch.268,Section I.
Applicant's Signature: ( A
Date: � t q ' i/1
Owners Signature(or atta hme t) Date:
Approved By:
Date:
Building Official(or signe 4EMAIL'17DDR1 l
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
3/22
7
_ \ The Commonwealth of Massachusetts
+=.= Department of Industrial Accidents
ie= 1 Congress Street, Suite 100
Boston, MA 02114-2017
`,'.; 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). J� C. stt y&L{ .--‘.
Address: (o ( ed(--) cC .t. KC/,
City/State/Zip: z c> t Mi4 Phone #: 60 ?OS _SZ)11
Are you an employer?Check the appropriate box:
Type of project (required):
1.[ I am a employer with employees(full and/or part-time).*
7C71 New construction
2. I am a sole proprietor or partnership and have no employees working for me in
any capacity. [No workers'comp. insurance required.] 8• — Remodeling
3t3
I am a homeowner doing all work myself [No workers'comp_ insurance required.]t 9 -- Demolition
4.[ I am a homeowner and will be hiring contractors to conduct all work on my roe I will 10 Building addition
ensure that all contractors either have workers'compensation insurance or are sole
l l.[ Electrical repairs or additions
proprietors with no employees.
5.[I am a general contractor and I have hired the sub-contractors listed on the attached sheet 12.U Plumbing repairs or additions
tr
These sub-contractors have employees and have workers'comp. insurance.I 1 •[—Roof repairs
6.[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 a quired under MGL c. 152, §25A is a criminal violation punishable by a fine up to $1,500.00
and/or one-year imprison en , 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 c py of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify u d r the pains andpe ies of perjury that the information provided above is true and correct.
Signature: , {V ) 'II r VV. ^ n
Date: �q , � �
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):
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 6FEET FROM SIDES AND
REAR LOT LINES.
FOR LOT
Indicate location of
Additions. w c- y building
Sewerageashed ----------
Sewerage dispose/ (oe8spo�) ----
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I
I
— (it............ ,tt,
rear) '
Abutter's —
'Q
Name I
Abutter's
-- — . .
Lot# I
I �� Name
If this is a Lot#
corner lot, REAR YARD
write in If this is a
name of street. •.•..• ..ft, comer lot,
•. .• V, L� write in
I name of street.
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•
3D b
I•
• SIDE YARD '
•
_ HOUSE SIDE Y -p
•
•
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•
•
•
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SET 8AC/
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......�,.ft. ;
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(lot.. ...............ft. frontage)
>I ± orrnation c-V
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