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Home My WebLink AboutBLD-23-000926 ?O Office Use Only r RECEIVED Permit# M n ATTAC SE G •��-��V-- O . °'°°..,,o,.rS pp Amount 3� c ri. Cl 2QtS Permit expires 180 days from 9 issue date BUILDING DEPARTMENT w (�. Z3-1�. EXPRESS SillP LICATIO TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: Q 4 S Wmoj lam, ' rook yam rd OWNER: Teter 1 .42d4. t . CC So,y ///aver Ri s-a,brei, 4/3-6- -8Q7 NAME PRESENT ADDRESS . Ai 6)373 TEL. k CONTRACTOR: a,M. sec 1�e/ a S ? Q4.Pn Ann Ie ,iarwi 1444 . S"06'- L f 3o 8 60 NAME MAILING ADDRESS 1 TEL.# 11.Residential Commercial Est.Cost of Construction$ 3ap(7 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 b , e Size L O x W /0 x H " JO Corner Lot: Yes t✓ 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 be built closer than twelve (12)feet to any other building on an adjacent par5l. All Iles are rgcLarired to be located thirty (30)feet from any front lot line Replace existing* Size L -{o x w q -x H 'O14l oLoL,J SW at •td, ciiii, AP- Add *The debris will be disposed of at: a,,QL3=.,, f4. 1,aL ) -I'p yar'**o t. 1 5L2 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. Applicant's Signature: �,�/L_ Date: ,rfrs /7� i Owners Signature(or attachment) Date: �vx„�3 )�fe4)-> Approved By: ✓�� / Date: (J C./'� - - Building Official(or designee :/ 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 0olo = The Commonwealth of Massachusetts a Department of Industrial Accidents _�/11= 1 Congress Street, Suite 100 �._ Boston, MA 02114-2017 • Ng SV•y`,s www.mass.;ov/dia \orkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information n Please Print Legibly Name (Business/Organization/Individual): ?.44 f' „ 7Z_ci ,L 1 Address: a lQ $ riff licit.• City/State/Zip: ,yotrAtemli M 4 Phone #: y/3 c7 5-- 8C..12 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. E New construction 2.0 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. [No workers'comp. insurance required.]t 9. E Demolition 10 I] Building addition 4. I 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 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. 13.El Roof repairs These sub-contractors have employees and have workers'comp. insurance.I 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.7 Other 152,§I(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. IContractors 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 er the p 'ns and penalties of perjury that the information provided above is true'and correct. 0 ,C �, 1 Signature: .�2, Date: /3 .�le-e5/ e -b1...: Phone#: y/3 - 7S 9 Ca-7 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 LIE PLACED A MINIMUM OF 30 FEET FROM THE FRONT LOT LINE AND A MINIMUM OF 6 FEET FROM SIDES AND PLOT PLAN REAR LOT LINES. FOR LOT # /_ 9 U_ / /� 1 Ihdicat7e location of � or y building G(Gt7` �G�1 Additions with dashed lines Sewerage dispel (cesspool.) ED Well az: I 1:::)- - � . Abutters 1 64 4 I 1 Name _ Abutter's Lot# 3J 'r? I sked I1 �i �I 37 LName ot# If this is a �;, A corner lot, ;/ e � If this is a write in `7 • corner lot, name of street. ft. �� write in name of street .loan MT F I • 1 a 8 4 '.� I 1 j SIDE YARD / : a• How SIDE YARD • • • SST BAcz • 3a ft. I I 1 i i 1 / IA n cr 0 Ey►addt c 4qi (NAME OF STREET)<-- — Information, . ?jer �p�0 • StrPP]frd by1 " i i ,