BLD-23-001027 O�'.Y9 $"12u 1212_
Office Use Only
c eY HDO . —Pi
Permit#
ct• MATTACM [SE'
=moo^^••: Amount
Permit expires 180 days from
issue date
EXPRESS SHED PERMIT APPLICAT !; ►, 3 6Di6a 7
TOWN OF YARMOUTH RECEIVED
Yarmouth Building DepartmentLI ;22J
1146 Route 28 AUG 2 5
South Yarmouth, MA 02664 _
(508) 398-2231 Ext. 1261 BUILDING DEPgRTMENT
By:
CONSTRUCTION ADDRESS: I2 4 �\O (D611/� }� .�,k,0,, ._, �G.3
(J r 4
OWNER: ke4.e..-Gt-1 CC ljvi l.d'i;4Vt /Z 7711f(j o Isr.)✓ om L/,t4-yG,.-„n p„,IIN S,-)% ?0 .l�Jv/i•—
NAME PRESENT ADDRESS TEL. #
CONTRACTOR:
NAME MAILING ADDRESS TEL.#
dential H Commercial Est.Cost of Construction $ A 00C)
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 k.,--"' Size L /13 x W 12 x H S Corner Lot: Yes No ''''. -
Per Town ofYarnroudt Zonin,e Br-Law Sec 203.5 Note T:
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, 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)feetfroin any front lot line
Replace existing* Size L x W x H
*The debris will be disposed of at: /Ex-a✓l
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 rev ation of my license and for prosecution under M.G.L.Ch.268,Section I.
Applicant's Signature: Date: 9/z-r-i2 Z__.
Owne
rs Signature(or attachment) Date:
Approved By: Date: 13---- -C --
Building O ial esia ee) EMAIL AD SS:
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
,em
Z2:F`�t 1 Congress Street, Suite 100
Boston, MA 02114-2017
"_
•
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
A licant Information
Name (Business/Organization/Individual): 4. Please Print Leaibl
Address: /2.. 4 1; ',) _.1ve
City/State/Zip: ,�.t�, ter-ora /�/ Phone #: _ 6 0_C C) t7 C
Are you an employer?Check the appropriate box:
I. I am a employer with Type of project(required):
—__employees(fun and/or part-time).*
2.E I am a sole proprietor or partnership and have no employees working for me in 7' eV construction
any capacity. [No workers'comp. insurance required.]
8. [] Remodeling
32'I am a homeowner doing all work myself. [No workers'comp. insurance required.]t
9. C Demolition
4.E 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 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' Plllmbip These sub-contractors have employees and have workers'com repairs or additions
p• insurance.: 13.E Roof repairs
6.❑We area corporation and its officers have exercised their right of exemption per MGL c.
152,§I(4),and we have no employees. 14.E Other
[No workers'comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy
T Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit
$Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state`whetherior not those e
employees. If the sub-contractors have employees,they must provide their workers'com indicating such.
p.policy number. entities have
I am an employer that is providing workers'compensation insurance for my employees. Below is the of
information.
policy and job site
Insurance Company Name:
Policy# or Self-ins. Lic. #:
Expiration Date:
Job Site Address: , i - ' ri, _
Attach a copy of the workers' cpen�compensation policydeclaration
City/State/Zip: p
Failure to secure coverage as required under MGL c 152, §25Ais a criminal violation page (showing the policy number and expiration date).
and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK punishable ORDER and a fineneof upo to$250.0050.00
day against the violator. A copya fine a
coverage of this statement may be forwarded to the Office of Investigations of the DIA for insurance
�e verification.
I do hereby cert under the pains and penalties of perjury that the information provided ab
Signature: ___ __ ove is true'and correct.
Phone#: (:2 i. " Date: �-� 'L'�
`� c?c,
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. Building
I. oarr Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6Contact Person:
Phone#:
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