HomeMy WebLinkAboutBLD-23-001805 �� n 0 U -(AIL 101►zi2
® � YAR Office Use Only
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`�, � Permit# ��`''�" 4• rpsc� [:t;'xa� Amount 55 ,0
Permit expires 180 days from
issue date
OLD -Z.3 -61)i2'6:
EXPRESS SHED PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department - ' ._.Q,V E 0
1146 Route 28 [OCT Yarmouth, MA 02664 2022 1
(508) 398-2231 Ext. 1261
BUILDING-
South NT
CONSTRUCTION ADDRESS: /'�'"5 AJT O >t� 6 C C,� __
41 itm Ruts Ceoss;d4
/c)/OWNER: LTE4. ifOSTE1< f L • /1,9, O/08 'f ``rr/3:53/" ors
NAME PRESENT ADDRESS ^ TEL. #
CONTRACTOR: pp pa �lii AQ1C�r� 2t p�� oZ? e.LevnJ S-t` . SD4g—34.a -4 c s(9
NA MAILING ADDRESS (pew., TEL.#
residential Commercial Est.Cost of Construction$ �®, pG
Home Improvement Contractor Lic.# tea ceq Construction Supervisor LAC'.# 0/79'7 e
Workman's Compensation Insurance: (che k one)
I am the homeowner the sole proprietor I have Worker's Compensation Insurance
Insurance Company Name: _.------ Worker's Comp.Policy#
SHED INFORMATION
New V Size L lei' x W tog x H ' " Corner Lot: Yes 1/ No /def.-
Per Town of Yarmouth Zonin,t 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)feel 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 IA �
*The debris will be disposed of at: 71a'4'-+11 G7eYf$4 LitI A19�1 L-G
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. j
Applicant's Signature: Le �i�fu'l/J 6 Date. //`/Z�Z7/
Owner gnature(or attachment) ��t Date: 3 'A
Approved By: _ Date'. !
Building Official(o signe EMAIL ADDRES
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
_-i-- /, Department of Industrial Accidents
=_'iii
'= 1 Congress Street, Suite 100
__IT �< Boston, MA 02114-2017
' ,,,�'` 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): "Pp`,,, j-j4z1Ce.,.//1/4P2
Address: ..90 C=G.,,,t) .�
9 ZC g%U
City/State/Zip: j�,C .to/.7' in� Phone #: 26 —4
Are you an employer?Check the appropriate box:
Type of project(required):
I. I a a employer with employees(full and/or part-time).* 7. _ New construction
2. am a sole proprietor or partnership and have no employees working for me in 8. Remodeling
any capacity. [No workers'comp.insurance required.]
9. E Demolition
3.❑ I am a homeowner doing all work myself [No workers'comp- insurance required.]r _
— 10 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.
13.111 Roof repairs
These sub-contractprs have employees and have workers'comp. insurance.x
n
6.❑ We are a corporation and its officers have exercised their right of exemption per MGL c.
14.7 Other tcle,O►1
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.
1.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 certify under the pains and penalties of perjury that the information provided above is true and correct.
Si,nature . � sL moo/-, Date: 1, 1Z6Z7/
Phone#: 5aA 3‘7 - G45'e, d8 ?�« 37I, -
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 #
Indicate location of garage or accessory building
Additions. with dashed lines
Sewerage disposal (cesspool)
Well a
1 1
I
,�- _ .
Abutter's I Abutter's
Name Name
Lot# I h Lot#
If this is a REAR YARD Q'�' If this is a
corner lot, �p( •yo corner lot
write in �� ft. �i write in
name of street. �� �� �� tlo (1b�' name of s reef.
g3 1et• iK
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la 40
SIDE YARD SIDE YARD : 4
HOME J
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• / -e/ _ ' 5/11JT O 1ee.i_
\ / (NAME OF STREET) eor v.,0) L0T
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/ \ Information
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Home I 16x12 Pergolas 1
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TOWN OF YARMOUT . LI
I JUN 3 0 RECO _Yi
Y`, :14*.0144 1146 ROUTE 28, SOUTH YARMOUTH, MA 02664-4451
Niide-%*- Telephone(508)398-2231 Ext. 1292-Fax(508)398-0836 COMMUNITY
DEVELOPMENT
OLD KING'S HIGHWAY HISTORIC DISTRICT COMMITTEE
APPLICATION FOR
CERTIFICATE OF EXEMPTION
Application is hereby made for the issuance of a Certificate of Exemption under Sections 6 and 7 of Chapter 470 of
Acts of 1973. as amended, for the proposed work as described below and on plans, drawings, or photographs
accompanying this application.
Type or print legibly: V, i°0 -7-
Address of proposed work:4/(4 /31.4-A4x31. edJE 6 4al.e" MapdLot# 4q -
Owner(s)4,1/1 . 6fie-optieft . ti os Mt< Phone
All applications must%submitted by owner or accompanied by letter from owner approving submittal of applIc9on.
Mailing address. lio 4 ric1eitStifir5 C.g055 - rOg.7 Year built.____42 ..___•____
EmailAith) 5 etti -2..C. 4 au.?) .2o in Preferred notification method. Phone 4//, Email
Aoent/COntractor MAI L-3) 6---A.Lted)64___ , Phone ft 50 8 3 6,227,7.,_Ce*Iii"
Mailing Address
Email 1/4 a 4 ''. ,
, Preferred notification method Phone 4' Mal
Description of Proposed Work(Additional pages may be attached if necessary):
F‘,.. ..e "ro(3 a t'..ic / -;.,1/chi Pete.'vail
Signed(Ovinei or agent) ..._441Z4 .e4-t--14---- • :7) • tqta-A-P-- Date
. owner icontractoriagent is aware that a permit may be requ,red from the Building Department (Check other departments,also.)
This certificate is good for one year from approval date or upon date of expiration of Building Permit whichever date shall be later
for Committee use only:
Approved Approv4 d s ,,.. r:. .1 I Denied
Amount Reason for denial
if. , ,_ _ -----
_
castvck#,
Rcvd by-_ _, _ _-_—_— OLD kilAYSIITG
Le.1 49$41,e,1 1 fli"--E al-
APPLICATION#
Date Signed 74M,R_____- Signed _,C20.--. 1411°__ r-`--
.
VS 2011
7" ..7:,•-.-r-x,mr ..a ;ii- s,.*"a%:.-z4.44,,,€'."-` '' T' 5.—r--.r 8e'w—weat,l,e—..a.yg-.o-.... .7. 3. a +P- r.,p.T.•*o+a+.w-Plf"",- ->I
ON.. _ TOWN OF YARMOUTH , RECEIVE D
:Via
HEALTH DEPARTMENT LO:T 05 2022
t41'
ce.\mo ` •;•
‘1!..„(, PERMIT APPLICATION SIGN OFF TRANSMITTALSG DEPARTMENT
' B y_ ---
To he completed by Applicant.
Building Site Location: Pl�/� /5,d,i/7-- Qe91/r' L / ''G '
Proposed Improvement: '"""` r o„ i 4 S�..- / . ) / c >4 ,/
Applicant: ;:,:lie- i .eti,z , i).p ic Tel. No.: -G(terr
Address: c`x= .', �--°. `2,- - Date Filed: /v / 12,c,=
**/fyou would like e-mail notification of sign off,please provide e-mail address:
Owner Name: -1 r I
Owner Address: !../4I P P 0,0 ani-7 c'v-= Owner Tel. No. / - -i f 3 53 t 447<
RESIDENTIAL AND/OR COMMERCIAL BUILDING
HEALTH DEPARTMENT: Determines Compliance to State and Town Regulations; i.e., Requirements
For Septage Disposal and other Public Health Activities.
Please submit three (3) copies of plans, to include:
(1.) Site Plan showing existing buildings, water line location,
and septic system location;
(2.) Floor plan labeling ALL rooms within building
(all existing and proposed) —
Note: Floor plans not required for decks, sheds, windows, roofing;
(3.) If necessary, Title 5 application signed by licensed installer
with fee.
REVIEWED BY: , DATE: i ! I
PL ASE NOTE
COMMENTS/CONDITIONS:
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