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HomeMy WebLinkAboutBLD-23-000726 CCUUZX it rz Office Use Only 0 to i, y O, I 16t, Permit# Amount 3 5,1 7) Permit expires 180 days from issue date EXPRESS SHED PERMIT APPLICATION 3-ddD/Zia TOWN OF YARMOUTH Yarmouth Building Department • RECEIVE D 1146 Route 28 South Yarmouth, MA 02664 � �~---�� (508) 398-2231 Ext. 1261 AUG 1 � Z CONSTRUCTION ADDRESS: TIMEi2. C,,,AN(� BUILDING DEPARTMENT �-?�AR+"toHTt-1 p rr - —R Ott\I J::G''��tGl)� �IA�C.HC'. �' _ — 7 g , r1ti�K. (*AMC** WOyc►rttMa�-rH ©2G-�3 f� \'\,�I1 PRESENT ADDRESS TEL # - CONTRACTOR: NAME MAILING;ADDRESS - — TEL R 'esidential D Commercial /OQ�r OO Est.Cost of Construction$ Home Improvement Contractor Lie.# Construction Supervisor Lic.# Workman' Compensation Insurance: (check one) am the homeowner 1 am the sole proprietor I have Worker's Compensation Insurance Insurance Company Name: Worker's Comp.Policy# / f SHED INFORMATION New r,/ Size /. 44 s NV g x H $ Corner Lot: Yes No / Replace existing* Size L x W x H *The debris will be disposed of at: �w)1 el,�� � L / - Location of Facility �7l I declare under penalties ofperjur)that the statements herein contained arc true and correct to the best of my knowledge will be just cause for denial or revocation of my license and for prosecution under M U I. Ch.268.Section I. and belief I understand that any false answers) Applicant's Signature: , / Date: .J � �Z... ��r.Z Owners Signature(or attachment) —Date:Y 12 2Z ✓.�-- Approved By: -- Date: III � �a� Building Official(or designee) EMAIL ADDRESS: Zoning District: I listorical District: Yes oleeNo flood Plain Zone: Yes /No Water Resource Protection District: Within 100 ft.of Wetlands:*** Yes /*No Yes .,,N o ***Note:Conservation review required if within 100 ft.or Wetlands 3i22 The Commonwealth of Massachusetts Department oflndustrialAccidents 1 Congress Street, Suite 100 c =`� _ �a� Boston, MA 02114-2017 ems www.mass oov/dia \`orkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/Individual): F'LO>E'l C. Address: 8 I City/State/Zip: (A) Yq2i-L.&)1 li h-tCe oz-(b'1)hone#: Q,`f 1 Ai(0 33�5 g Are you an employer?Check the appropriate box: Type of project(required): l.❑I am a employer with employees(full and/or part-time).* 7, New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in any capacity.[No workers'comp.insurance required.] $• Remodeling 3. voi aim a homeowner doing all work myself[No workers'comp.insurance required.]r 9. CI Demolition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 [] Building addition ensure that all contractors either have workers'compensation insurance or are sol 11.[]Electrical repairs or additions proprietors with no employees. 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet12. Plumbing repairs or additions These sub-contractors have employees and have workers'comp.insurance.t 13.❑Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,31(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$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 do hereby certi der the pains and penal . perjury that the information provided above is true and correct. Signature: l//a �.Date; / • Phone#: CI"6I o'Z6 Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): I. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: • • PLOT PLAN FOR LOT 13 Additions. with ed ox acTsciry b d Sewerage died ( �) ® - - .._____ WeI,I 'sr j1 jj I t�t.���;,.F1,7 .. rear) t Abutter's 4 Name 1 -- Lot# 1 Abutter's H .t,.a✓MG% 1 Name CZZ�,4T24GG If this is aREA� YARD Lot# corner lot, write in this is a name of street. ................... corner lot, write in -. 1 name of street. • Asi$ c- ' f a r •o 4 . i9 e r 2i2_...ETA. (', HOUSE SIDE YARD • a ..Ti .• ... ' SET BACK • • A v o, • .......,.ft. • • I (lot..$•`•..,y‘.... -ge) (NAME OF STREET.'} / / t SuPPlied by 64G-GrvC- 1— A"krC.-Ft��