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Home My WebLink AboutBLDE-23-000377 s:o.YAR* a \�70 Office Use Only fri- " �•yb Permit# o2�� MATTACM ESE , Amount 3 S. Oa Permit expires 180 days from issue date i30 -02,3 -0003'77 EXPRESS SHED PERMIT APPLICA. • h. TOWN OF YARMOUTH R D E Q D Yarmouth Building Department _ - _ �-~-� 1146 Route 28 ,�L 2 2D22 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 BUILDING DEPARTMENT Acp•vaezzBy: CONSTRUCTION ADDRESS:.Xj , i tj 24d i J�' Yh/, lJ /1ifyir/� /�i�c!y�'J� /.� V OWNER: NAME PRESENT ADDRESS TEL. # CONTRACTOR: NAME MAILING ADDRESS TEL.# . / ,esidential Commercial Est.Cost of Construction$��p va Home Improvement Contractor Lie.# Construction Supervisor Lic.# Workm 's Compensation Insurance: (check one) V 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 Size L/y, �a x W /Q / x H '(4 // Corner Lot: 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 feel or less and single story, shall be six (6)feet in all districts, hut 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: f.ii"N e 4` b I4 A j V- H4,000 1 1 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) wi a just cause for deni.* revocatio f my ' ense nd for prosecution under M.G.L.Ch.268,Section I. Applicant's Signature: �/'% e r/� Date: Owners Signature(or attachment) ::::: k5sr---;"2� Building Off • or d gnee) AEMAIL ADDRE 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 _=+c = i Department of Industrial Accidents W =�,d 1 Congress Street, Suite 100 ° �r Boston, MA 02114-2017 •.i 5•• www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly ame (Business/Organization/Individual)*A14>/iti,A9 ,e,-2' J4 eA 9.,t1 f J 42e Address: .ef eid 4,r� ,„943 - - City/State/Zip / 6 /' Phone #: d/cL 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. Sew construction 2.[11 I am a sole proprietor or partnership and have no employees working for me in 8. E Remodeling any capacity. [No workers'comp. insurance required.] 3. I am a homeowner doing all work myself 9. C Demolition y [No workers'comp. insurance required.]' 10 — Building addition 4.dam 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 11. Electrical repairs or additions proprietors with no employees. 12. 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.t 13. Roof repairs 6.D 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 ce ify and the ains and penalties of perjury that the information provided above is true'and correct. /Signature: d' ;t Date: y Phone#: lD/ 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 # D'hdicabe lacat as of garage or accessory building Additipis with dashed ,lines Sewerage deal (cesspool) 49 Well fg/ I 0E I oat _._. — ._ tt. rear) I Q - - . Abutter'sI i 4' Lot* rI Abutter's Name Name Lot* If this is a REAR YARDr-------k-i°-corner lot, , If this is a writer . / corner lot, name of street. ft. write in '' - r name of street. I . ... I I SIDE YARD SIDE YARD • ' .0 _— .FTs. HOME2: • t • SET BALE • y.. I l (lot 761 ' ft. fruitage) • / fi1/ 4fL ezd f 2442y if2t,-, / (NAME OF STREET) / Information Supplied by a.eg, , '�