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llome lmprovement Contractor Lic. #
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Construction Supervisor Lic. #
SHED INFoRNIATI ON
Corner Lot: Yes No
TEL #
Est. Cosr ofConnruction $ /Daa 4.a€ '/
,q ("VSD
Nov 16 2023
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Itt hc locutel thirty (J0) feel fi.ottt utn
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'li'otrt ktt lina
Replace existing* _ Size L- _x lt x H
. rhc debns nr h{ drspo\cJ ot ar - &utly<a l..ldrhtrti0n ol a(ililr
ldrclare und.r penaltlcs ol
t!rllbrJusl cause lbr dunral
fequr\ that thc iatcnlcnts heretn ronliltncd ar. true and corrc!t (r the best ot nn kno$l
cen\e and for p(rsecution undcr lV C t. Ch 268. Section I
eds!, and hehcl' I undcrshd that anr lxlrc ans$e(s)
pplrcant s Stsnaturc
(hrners Sigraturc (or atllichment l):llc:
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Zoning District
Ilistorical Districl: Yes r-o Flood plain Zonc: yes
Watcr Resourcc Prolcction District: Within I00 ft. ofWetlands: ***Yes No yes Nor**Nole: Conserraiion re!ie\r required if$hhin 100 fr. of Wetlands
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EXPRESS SHED PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
I146 Route 28
South Yarmouth , MA 02664
(s08) 398-2231 Ext. t26t
{on.r*r.r,o*ADDRESS:,ry drrftu t\,lt. M{-!r*!r/L_
Workman s Compensation lnsurance. (chccl onc)y'l am the homco*ncr I am the sole proprietor I havs Worker.s Compcnsation Insurance
lnsuralce Compan]'Namci _ !['orker.s Comp. policytr_
_oare //-a./O-*aA
s-\The Conuaonwealth of Massachusens
Departrnent o! I ndustrial Accidents
I Congress Street, Suite 100
Boston, MA02lI4-2017
www.mass.govklia
\1'orkrrs'Compcnsatioo losurrncc Allidrvit: Buildcrs/Cootnclors/ElccJriciens/?lumbcrs.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Name (Busincss/Organization/lndrviduai)
Address: 2.5Q Que<rrt
Mc Ccra+h Qo,r.} ho C cooca +i(M\
Ar,n" Q"\
CirylSarclZip Hc\rL\r,U^, M+ Otioqs Phone#. 6(;g - qb'^800
Ar. you ro .eploycr? Ch..t tt. .rrropri.t. bot:
I [| I am a cmploytr *i,r, -!$-.rptoy"., {full and/or pan-trmc) '
2 flI rm o solc popricror or prnn Rhrpand harc no cmplolecs *orktnt for mc in
r,ry crpacity [No *orkcrs' comp insuran c rcquir?d ]
3 ! I rrn a homco*r,", dojnt all $ork hys€lt [No *erls15' 6p119 ansuranc. r.quir.d ] '
I ! | am r homcoumcr and wrll b. hl'rng co[tractors to conduct allwork on ny prop.ny Ir{ill
ansuc $al all conlr:rctorr citlEr havc *orlcrs'compcnsation insurarca or aJc 5ola
propalators with no cmployccs
5 ! I am a gcncral conrraclor and I hav. hrr.d thc sub{onraclors hst d on thc atlach.d rhcer
Thasd sub-contacrcG hava cmployaas ard hala lrork€rs comp msuranca :
6 [ Wc uc a corporation and trs offic.rs havc .x..crs.d lh.ir right ofcxcmption pcr MGL c
152,51(4).snd wc havc no cmploycis [No wo crs'comp insu[Dcc rcqujrcd ]
'Any appllcanl lhal .h.cks box * I must ,.lso fill ou thr s.ction b.low showrnt th€ir $orkcr'' compcns.tion polrcy infonnationr Homco\rncrs rrho submrr th,s .6idrvrl indrcatint thcy arc doing all .rork ui rh.n hrc outsrdr contrictors musr submir a nrw aflida! n rndicarrng such;Conu&tors lhal ch.ck dtls box must atlacll.d an .ddrironal shcat sho, ng thc naha ofthr sub-conlraclors and srda whath.r or ool thosc cntiti.s halacmploy.6. lf th. sub{odractors havc.mploy.cs, rh.y musl provid. th.ir wo.kc6'comp policy nt|Inbtr
I am an cn Ployct thdl is proiding workcn' conEensolion insunnce /or nry enploye cs. Bclov, b the poticy and job site
infomation
Insurance Company Name l.{€.rn lo an
Job Site Address Crty/Shre/Zip
Atlr(h a copy of thc workcrs' compcnsatioD policy dcclarztion pagc (sbowirg lhr policy ouInbrr and crpiration drt.).
Failure to secure coverage as requircd under MGL c 152, $25A is a criminal violation punishable by a fine up to $1,500 00
and/or one'year imprisonment, as well as civil penalties in the form ofa STOP WORK ORDER and a fine ofup to S250 00 ada) against the violator A copy of thrs statcmcnt may be forwarded to the Ofiice of Invcstigations of the DIA for insurance
cov€rage verification
I do hercby certi/y penalti
Sr
es ofperjury thqt thc inlomation proidcd obovc tru
Date L z3
one ,
Typc of projccr (rcquircd)
7. ffiew corstruction
8. fl Rcmodeling
9 ElDemolition
l0 E Building addition
ll El Electrical repairs or additions
l2 E Plumbing repairs or additions
ll lRoof repairs
14 Dorher--
th
Offrciol usc on$. Do not wite in this neo, to be congletcd by ciry or ,own oI/iciol
Cit-v or Towo: _ permivlicc[sc #
Issuilg Aurhority (circlc oac):
l. Borrd ofHcalth 2. Building DcperrD.trt 3. City/Tord! Clcrk
6. Oth.r {. flcctricel losptctor 5. PluBbing Iuspccror
Phooc #:
Applicrnt luform.tior Plcasc PriDt L.giblY
Policy#orSelf-ins Lic # ECC-GOO - Lit\03q5rl -a0aq4Expiratrono.t. Ju[t\ 8,lOALI
and corrccl
Coatrct Pcrsoo:
t'
w
J h,e {oqrrutn'sntx<'a& gt Jt4zzaarluu*&- 'Oin
" of Consuglcr Affairs and tug'incsvRegulation
I0 Park Plaaa - Suite 5I70
Boston, Massagfryicts 021 l5
Home lrirp,rovemcnt ftStor Rcgistation"
CI CorYmonxadlh ot ltaarlchua.ttr
DlYtalon ol Occupr0o l LlcanauraBo.rd of BulldlrE illgl.lbor .nd St nd.rdr
conatrucuggtrtil*{llbrr1 a 2 FamityMcGRATH POST & BEAU CO'
di[?#{ffi;HH
cSFA{t738C6
JAME8 R
2U
BREWSTER
2t,
E
it..i 0U1412024
to
commrrdomr d,rrA I. dbi^.
THE COMMONWEALTH OF MASSACHUSETTS
Ofiice ol Consumer Business Begutation
t00o w - Suite 710
118
Home I
Tlpe:Corporation
1329}5
10t.3IJt2024
T}€ COIrcNWEALTH OF H SSACHUSETTS
Ottlc. o, Collunr.Btdrs! ntgublron
YCGRATH POST &
i,/ts/A PINE
n gl.laOon va{d lo. bdlvl(lJal ua. only b3lor! tio.rp&t0oo dab. lrlbura [hrm bl
Ottb. ol Corum.r Artlrt ltd Bs.lncn R.euh&on
tO@ Wrtltntgbo St!.| . Sult 7t0
3onon, l.A mir8
U9d.t Addna. arld ntturn Crd.
4,o/.,,*JAMES R, MCGRATH
259 OUEEN ANNE AD
tlARWtCH. MA 02645 Undorsocretarv Slonature
MCGRATH POST & BEAIT CO.
O/B/A PINE HA88OB WOOD PROOUCTS
259 OUEEN ANNE BD.
HARWICH. MA 02645
ltoE
The Commonwealth of Massachusetts
D ep artme nt of I nd ustri al A cc idents
1 Congress Street, Suite 100
Boston, MA 02114-2017
www, mass.gov/dia
n lnsu rance Af{idavit: Builders/Contra cto rs/TO BE FILED WITH TEE PERMITTINC .A.I-TTHO RJT\'
,5 ll-
El ectricians/Plum bers.
se Print bI
\\:otkers' Compensatio
tIn a n
Name (Business/Oreanizarion4odividual) :
Address:q e{L)
PI
Phone #: '5tB -,{id - Szoa
li
t)L
City/Statelzip u.)C 0
*Any applicanr rha! checkt box #l must also fill out thc section bclow showjng lhcir work.rr'coopcnsalion policy infomatioLi Homcovr'rcB who submi! thls affidavit indicating rhcy are doing all work and then hir. outside con!'acrors musr submir a new affidavtt illdlcatrnt such.lContractors !ha! chcck this box must attachcd an addilional sheeishow ing th. namc ofthc sub-conEactors and slate whethcr or not thosc entities havcemployecs. If thr sutscon!-actors have employees,'J:ey
I am a amployer with _cmployecs (full and/or pan-ume).*
I arn a so'e proprictor or paroeship and have no employees workrng for m. inany capacity [No wo,licrs'corhp. rnsurance rcquircd ]'
ing all v'ork myself. fNo workers'comp. rnsurance requircd I i
I am a gEocral con!-actor and I have hircd thc sub_con!-actor5 lislad on the aftachcd shccrThcsc sub-conu'acrgrs have cmployces and hav" *ork".r, ;o;;.';;;:.i*'* -'
Wc ara a co4)otaoon and trs officeB hava axcrclsed rhelr nght ofexcmDtlon DcI52, S l(4), and wc havc no .hployees. tNo *o,k.rr, "o;;;.;;; ;;:;
)
5
oyecs
n y'*
" no^".r"r,.,and will bc hiring contractors to conduct all wori( on my properry I willeithcr havc workcas' compcnsation insurarceensure lhat all contraciors or ate solepropnetors wllh no cmpl
! I am a homeowner do
rMGLc
l
Art you an employcr? Ch.rk thc 2ppropriar. bot
Type of project (required)
New construction
Remodeling
Demolition
Building addition
Elect'ical repairs or additions
Plumbing repairs or additions
Roofrcpairs
Other
7.
a
o
l0
II
t2
l3
l4
must provide tbeir workers'comp. poljcy number
I am an employer that is providing workers,
in/ormatio n compensation insurancefor my emplo)ees. Below is the policy and.job site
lnsuraace Company Name
Policy # or Self-ins. Lic. #
Job Site Address:.-o,r,.o,.oryor ilo,lr.rffili",**.* *;r.**.,Failure to secure coverage as required underMGL c. 152, $25A is a criminal violation punishable by a fine up to $1,500.00and/or one-year imprisonment, as well as civit penaltiesin iie ronn oru srop woRKbRDiR;Ja fine of up ro $250.00 a
.do"#:X5.}|.o1,"#r' A copv ortnt 'tut""ni ,*l;;;;;,. the office of rnvestisations of the DrA for insurance
I do hereby cer und.er the pains andpenalties of perjuryArd the infomation proyided above is trud and correct.
Date - a^ -Z
Phone 508 --6/66
City or Tolyn:Permit/License #
4. Electrical Inspector 5. plumbing lnspector
Pho oe #:
Offtcial use only. Do not wtite in this atea, to be completed by city or tolvn ofrtcial
Depanment 3. CirJ /Town Clerk
Contact Person:
Issuing A utho riry (circle one):l. Board of Health 2. Buildine
6. Other
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