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Home My WebLink AboutBLD-23-000053 I4Office Use Onnly�.. �p Permit# F'^r'�"[� CMYS 2 Amount 3� Permit expires 180 days from issue date - 64.53 EXPRESS SHED PERMIT APPLICAI I )- C 1) I V D TOWN OF YARMOUTH 4E E Yarmouth Building Department JUL 01 2022 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 BUILDING DEPARTMENT By: CONSTRUCTION ADDRESS: 30 t krt...0 s c 41 i , ` 5 i ya r uc u k u v 1 OWNER: !'1A-L.Ltd. V 1(anCCA. SXLU O et.b0, - —36-1 L I%I NAME PRESENT ADDRESS TEL. # CONTRACTOR: 51)(! '3617 — L1 13` NAME MAILING ADDRESS b TEL.# ezesidential D Commercial Est.Cost of Construction$ +gL Home Improvement Contractor Lic.# Construction Supervisor Lie.# Workm' 's Compensation Insurance: (check one) I/ I am the homeowner I am the sole proprietor 1 have Worker's Compensation Insurance Insurance Company Name: Worker's Comp. Policy# SHED INFORMATION /New . Size L g- x W lil9 x H Corner Lot: "'t. Yes No Per Town of Yarmouth Zoning By-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 story, shall be six (6)feet in all districts, but in no case shall said accessory buildings he 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: XA f t i f # 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 revocation of my license and for prosecution under M.G.L.Ch.268,Section I. gpplicant's Signature: Prk--`k C 4E C� i t✓/ Date: 3-l'� 1 4a� Owners Signature(or attachment) `//� Date: Approved By: �+1 Building Offici. -ir d/-,nee Date: !/` EMAIL ADD S: 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 The Commonwealth of Massachusetts• Department of Industrial Accidents n::rram 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.massgov/dia imo . Workers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. A licant Information aim (Business/Organization/Individual): Please Print LeQibl Address: ' IALti City/State/Zip: ( �, `, �� VVi Phone #: f Are you an employer?Check the appropriate box: �3 1. I am a employer with employees(full and/or part-time).* Type of project(required): 2.0 I am a sole proprietor or partnership and have no employees working for me in 7. New Jelin construction any capacity. [No workers'comp. insurance required.] 8. Remodeling 3.❑I am a homeowner doing all work myself. [No workers'comp. insurance required.]t 9. C Demolition 4 am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 10 Building addition proprietors with no employees. 11. Electrical repairs or additions 5.❑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 13.E Roof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 152, §1(4),and we have no employees. 14.C Other [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 p and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of upto$250.00 by a fine up to $1,500.00 day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance a coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true'and corre �ianature: k • ct. c t t. Phone#: Date: 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 # oar I. Board of Health 2. BuildinQg. oarr Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector Contact Person: Phone#: PLOT PLAN FOR LOT Indicate location of Additions wgara y building Sewerageed --- --_�-- Well 0 dui (cesspool) ® ---- I __-__ ___- _ ( ......... ......tt. Abutter's Q' Name 1 Lot# 1 Abutter's . VW Name If this is a REAR YARD 1 Lot# corner lot write in If this is a name of street. ........ corner lot �•�•• write in I • name of street. 4 o pwc- SIDE' YARD I '' NOOSE- .ZT () USE ._ • B YARD • 40 • SST BACK • : • 4 ..... I oat ..........ft. fin ) N. / (NAME OF --_7 STREET) / \ Information Supplied by