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Home My WebLink AboutBLD-23-001807 s. � (��5� �� 0, ' RR rr L m 16 I M I Z2 Office Use Only �� 1Gi j 421-Permit# l yp` yMATTACM p!, Amount 3 5 -03 Permit expires 180 days from issue date EXPRESS SHED PERMIT APPLICA 6 �3 ' bh 1b'7 TOWN OF YARMOUTH R E C E I V E Yarmouth Building Department - -.,... . ..[ ; i ._ 1146 Route 28 OCT �5 22 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 BUILDING DEPARTMENT •��J,, By: CONSTRUCTION ADDRESS: 6/ 464 e OP --- — OWNER: iedeld/zl 44/ CDl i // (DI7"'9.c,.G y NAME RESEN ADDRESS TEL. # CONTRACTOR: NAME MAILING ADDRESS TEL.# Iesidential Commercial Est.Cost of Construction$ -3r�"7,6 -- Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman's Compensation Insurance: (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 4 Size L 6 ' x W Asti x H A2' Corner Lot: Yes No k" 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)feel 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 anyfront lot line 6dm< 'va---ildr) aio prairie Replace existing* Size L x W x H *The debris will be disposed of at: —.70—t.t_JA/ 0. ///y) j ocation 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 revo tion my license and it prosecution under M.G.L.Ch.268,Section I. Applicant's Signature: ✓ / Date: d Owners Signature(or attachment) / Date: y Approved By: ,l,ry 7/ Date: ./o �// Building.Official(or d ne / EMAIL ADDRESS: 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 A -�:i1= Department of Industrial Accidents -eI� 1 Congress Street, Suite 100 _'o mow ^ Boston, MA 02114-2017 •�� zr �s•` 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): Address: City/State/Zip: Phone #: Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with employees(full and/or part-time).* 7. /I! New construction 2.E I am a sole proprietor or partnership and have no employees working for me in 8. El Remodeling any capacity. [No workers'comp. insurance required.] _ ' 3.X1 I am a homeowner doing all work myself. 9. _ Demolition y [No workers'comp. insurance required.] 4.❑I am a homeowner and will be hiring contractors to conduct all work on m YP roPam' e I will 10 n Building addition ensure that all contractors either have workers'compensation insurance or are sole 11. Electrical repairs or additions proprietors with no employees. 12.E 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.x 13. 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. 1Contractors 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 penalties of perjury that the information provided above is true'and correct. Signature: ��"=�L 0 6 �,�,� .3� Date: ��.c C' e Az— Phone#: 6 f?-- 9, 1, 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#: PLOT PLAN FOR LOT # Indicate location ce garage or accessory building Additions- with dashed lines Sewerage disposal (cesspool) (59 Well fa 1 (mot /40 e.J0 ft. rear) -- - -- Abutter's I 7 Name / Abutter's Lot# � I 1`..31/.."..0..1 Name Lot# If this is aREAR YARD If this is a corner lot, write in corner lot, name of street. I ft. write in name of street. 'o • 4,› � I � SIDE YARD HORSE SIDE YARD • SET BACI ft. (lot 4 ..2 ...it. fruitage) / ZQ /ea / (NAME OF STREET) Info med Supplied by y 'n CONSERVATION 3� } OFFICE o b,s-/�"\MATTA K r Yarm h.ma.us ?,�' o.✓ � onservation Yarmouth Conservation Commission Commission Administrative Review Applicant Information: OCT 06 Z022 Name: € / M ' a Mailing Address: f girl defy ki.. d/e ' a Phone: 4/ .-qZ,2,4 6'6 Email: I hereby authorize the individual members of the Yarmouth Conservation Commission and its agents)to enter upon the property listed below for the purpose of gathering information regarding this Administrative Review form. Property/Location of Work: 6/ 8�y/Pi2i4 �� / Stree ame and Number Signature: X / Detailed Description and Reason for Pro o ork: 7/Ye,P S 5'X/2' Q /2'XA2/ Closest Distance to Resource Area: T676 /,e Proposed Start Date: /7,i- J11a1 40- 7(- i' ./'�� Company to do Work: Name: t53`o/•-• Address: , , Phone: Email: Administrative Approval: t o i 1 5 2Z prov-eck- 514Ack5 . nAvS)- bf secs��iy 34- d p f orr't ;e S Or Smoi-d4X> ft2Nutp This approval is valid for one year. This Approval does not grant any property rights or any exclusive privileges;it does not authorize any injury to private property or invasion of property. Yarmouth Conservation Commission•1146 Route 28,South Yarmouth,MA 02664•(508)398-2231•Ext 1288