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Home My WebLink AboutBLD-23-001772 Ur 1 0 Of ice Use Onlylt°\4 /�' '';2",' Permit# 1.,�-'►' iS /5 �M�0 {SE_�/ �' Amount 3 c. Permit expires 180 days from issue date f3 bD --a/3 60 17 7z EXPRESS SHED PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department RECEIVE D 1146 Route 28 - - South Yarmouth, MA 02664 LSEP 3 O 2022 (508) 398-2231 Ext. 1261 vi CONSTRUCTION ADDRESS: Z lld4i'-e r-f CI rcl l4 Yet rul 0 c.,1-'4 [ BUILDING DEPARTMENT VOWNER: o f r e, 6 r 0 ��e‘. �s0 0 7 2 Z 6 d NAME f $,.,c// PRESENT ADDRESS TEL. # CONTRACTOR: R.fQCIS F ,-.7 fivrii... l,,L 3 i rgcj C¢c,c NAME MAILING ADDRESS ` � �7 3 TEELL.# residential Commercial ❑ Est.Cost of Construction$ 100 — // Home Improvement Contractor Lic.# Construction Supervisor Lic.# Workman Compensation Insurance: (check one) VI am the homeowner I am the sole proprietor I have Worker's Compensation Insurance 'Insurance Company Name: Worker's Comp. Policy# SHED INFORMATION New Y Size L—_ x W—__ x H �/ Corner Lot: Yes No Per Town of Yarmouth Zonin,By-Law Sec 203.5 Note E: Side and rear yard setbacks for accessory buildings containing one hundred r 150 square feel or less and shall be six (6)feet in all districts, hut in no case shall said accessory buildings he closer than twelve 12)singleeertoanyy, other building on an adjacent parcel. All sheds are required to be located thirt 30 eet ronr an front lot line 7 �eet any Replace existing* Size L 8 x W 8 x yJ The debris will be disposed of at: 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: �// / Date: Owners Signature(or attachment) v__ �� ..r./� Date: ��..O�Z Z Approved By: �XgArgif Building Officer d ..bne-e) EMAIL ..% Date / - DRESS: Zoning District: Historical District: Yes No Flood Plain Zone: Yes No Water Resource Protection District: Within 100 ft.of Wetlands: *** Yes No Yes o ***Note:Conservation review required if within 100 ft.of Wetlands 3/22 • The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass aov/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): C, /Address: /? fy h o it 4 City/State/Zip:_ `, M/4 ,75 2 Phone #: (Cog ) 7? g - 2 6 Are you an employer?Check the appropriate bax: l. I am a employer with Type of project(required): employees(full and/or part-time).* 7. — 2.E I am a sole proprietor or partnership and have no employees working for me in New construction any capacity. [No workers'comp. insurance required.] 8. n Remodeling 3. I am a homeowner doing all work myself. [No workers'comp. insurance required.]' 9. C Demolition 4.VIam a homeowner and will be hiring contractors to conduct all work on my roe I will 10 Building addition ensure that all contractors either have workers'compensation insurance le proprietors with no employees. 11. Electrical repairs or additions or are so 12.n 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.: 13.[]Roof repairs 6 C We are a corporation and its officers have exercised their right of exemption per MGL c. 14.7 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: 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. S-ianature: Phone#: Date: ,P/?�/? 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# I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector . Other Contact Person: Phone#: • PLOT PLAN FOR LOT # IhdiCarbe location Addiido s with h or -Y build-- --- �-- Weu ® disposal (cesspool) ---- Sewerage __ 1 J1 (kit............ .i`t. -. rem) Abutter's Q ' Name ‘�F Lot* I Abutter's I Name If this is a REAR YARD 2:::::- (÷ Lot# corner lot, write in /74 If this is a name of street. ........ ..ft, corner lot, write in 1 d.-1- name of street. I i I 4 • SIDE YARD • HOt75E SIDE YARD • • • • • • • • • SET BACK • • • • 'd (lot..................ft. frontage) • /� Imo' " �S 6 r4 INAMB OF STEET) / \ Infor . mat Supplied by