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HomeMy WebLinkAboutBLD-23-000702 a , 5 YAR,. po U I1 1 1z Office Use Only v, O. l tt t l�-lya Permit C S�`^r 4o.o a Amount , Permit expires 180 days from issue date B LP -023- 6/O7®Z. EXPRESS SHED PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department RECEIVED 1146 Route 28 South Yarmouth, MA 02664 AUG 112022 t l (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: a o V I9 S c r i SQ" G) (t7MG B' UILDING DEPARTMENT '^ /� OWNER: n Cr�,�L- 9 kcc1 al t..,z. E S �.lg.,48,cy/.L Lob -(( 7.03®7 NAME PRESENT ADDRESS TEL. # CONTRACTOR: NAME MAILING ADDRESS TEL.# Residential Commercial Est.Cost of Construction$ /S ID Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman's Compensation Insurance: (check one) XI am the homeowner I am the sole proprietor I have Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy# SHED INFORMATION / t QI l New ✓ Size L I), x W V/L x H 1 1 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 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: tk Location of Facility I declare under penalties of pe iry that the : =• ents 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 , cation i my li -nse Aliafor prosec in under M.G.L.Ch.268,Section I. + all Applicant's Signature: Date: O I �� Owners Signature(or att: nt) \li 10 Date: Approved By: gr., Date: — \\ Building Official a• signee) EMAIL ADDRESS: Zoning District: Historical District: Yes No Flood Plain Zone: Yes N, Water Resource Protection District: Within 100 ft.of Wetlands: *** Yes Yes No ***Note:Conservation review required if within 100 ft.of Wetlands 3/22 i The Commonwealth of Massachusetts P = a_ / Department of Industrial Accidents ve 1 Congress Street, Suite 100 =M IMI t Boston, MA 02114-2017 /. 5,.�MIMN www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers- TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): 011 n C^pt,,,44.4./- Address: , e3 �t r I'fi r% W 1 ei rn4, City/State/Zip: (,� Ctrrn O),03 Phone #: - ,-08 - 647 - 6-'337 Are you an employer?Check the appropriate box: Type of project (required): 1._I am a employer with employees(full and/or part-time).* 7XNew construction 2.E I am a sole proprietor or partnership and have no employees working for me in - $. E Remodeling any capacity. [No workers'comp. insurance required.] 9. C Demolition 3. am a homeowner doing all work myself. [No workers'comp. insurance required.]' 10 7 Building addition 4.C 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.E Electrical repairs or additions proprietors with no employees. 12._Plumbing repairs or additions 5.E I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑ROOF repairs These sub-contractors have employees and have workers'comp. insurance.: 6.E We are a corporation and its officers have exercised their right of exemption per MGL c. 14.E 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 verificatio . I do hereby certify the p ins iindpenalties perjury that the information provided above is true and correct. Signature: J Date: —` ( — Z.Z. Phone#: Official use on . 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#: • CC.) Imo' PLOT PLAN V�r `' CI, FOR LOT 6 mate locatico of garage tar Addition, w Y building Sewerageed lines disposal (cesspool) Well >S 1 _. ._ I (kit ..............ft. rear) 1 c I Abutter's Q Name 'all Lot* Abutter's I Name Lot# REAR YARD If this is a corner lot, �-`jL; If this is a write in Corr name of street. ft• write plot, " _ 2' I name of street. 8 •o 4 I SIDE YARD �]. __. .ET r• �• HOUSE SIDE YARD • I • SET BACK waft 'K ff 'so' '�v �C ......II (� ,.f�. . (lot ft. fiuntage) 2- © U ; n S' • (.) ? . (NAME OF STREET) 3 € — / / Inf a-match r. Supplied by