The URL can be used to link to this page

Home My WebLink AboutBLD-22-007275 IP\ (gi C Pe 0/2-/Iz2 Office Use Only ly ��,, h r,,,__ �,E; Permit# .__Lt�r 4 Amount i Permit expires 180 days from issue date EXPRESS SHED PERMIT APPLICATIOIIT -�D�7� TOWN OF YARMOUTH RECEIVED Yarmouth Building Department 1146 Route 28 JUN 16 2022 South Yarmouth, MA 02664 j (508) 398-2231 Ext. 1261 BUILDING DEPARTMENT Vr CONSTRUCTION ADDRESS: ) 141A.S514 GvtJs.e2, — By -"'�-- �S A\l� �)� 1/a�n�tov MA o 6 73 NAME - IBC ` S AVL A .‘j O2c?3 PRESENT ADDRESS ___��a� TEL. # CONTRACTOR: 5- �\nib; NAME MAILING ADDRESS • TEL.# residential ❑Commercial ,,Est. Cost of Construction $�(1 joeL(� 2 1.0/ Home Improvement Contractor Lic.# ; .( A .tt.; Construction Supervisor Lie.# Workman's Compensation Insurance: (check one) .4I am the homeowner I am the sole proprietor 1 have Worker's Compensation Insurance Insurance Company Name: Worker's Comp. Policy# 41ew SHED INFORMATION Size L to x W _xH 1L' 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) feet shall be six (6)feet in all districts, but in no case shall said accessory buildings be built closer than twelve (12)feet to any y other building on an adjacent parcel. All sheds are rec uired to be located thirt 30 eet om an ront lot line Replace existing* Size�L x IF x H /*The debris will be disposed of at: Armai4k. G .1,,ee- oca ' n 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 1. Applicant's Signature: w Date: Owners Signature(or attachment) v\ Approved By: r� Date: („, �i ( � Building Official(or desig Date: 77 MAIL ADDRESS: Zoning District:_ Historical District: Yes No Flood 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 nompalt=`' — Department of Industrial Accidents 1� t. 1 Congress Street, Suite 100 • =`= I. Boston, MA 02114-2017 ..1'...s www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. A licant Information Please Print LegibI Name (Business/Organization/Individual): :014.)—, WC--)_.. Address: 1 Vto 4,S A46. .0 rMv k A 0k7 City/State/Zip: LOW V6f tt1C1 t ,vv4 62413 Phone #: ct? 333 - nO3 Are you an employer?Check the appropriate box: 1.— I am a employer withType of project(required): er emp loyees y (full and/or part-time).* const2.E I am a sole proprietor or partnership and have no employees working for me in 7. — New de1in CtlOn any capacity. [No workers'comp. insurance required.] 8. Remodeling 7 3. I am a homeowner doing all work myself. [No workers'comp. insurance required.] 9 — Demolition 4.lam a homeowner and will be hiring contract ors to conduct all work on myroe I will 10 n Building addition ensure that all contractors either have workers'compensation insurance or are soleTy _ proprietors with no employees. 11,_ Electrical repairs or additions 5.�I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 12. Plumbing repairs or additions These sub-contractors have employees and have workers'comp. insurance 13.E Roof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. I4.]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 thetpolicy 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 /ianature: Gh.��, /Date: I 1 2— Phone#: 1?g-333-Ob3 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# 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing In 6. Other specto r Contact Person: Phone#: 12 Ik4 41/ itell 15 :-.: ..e.,. ..:.1*1.':;',..1diii' ft,,d lig * ...-'1. . . ' • �� j iEr7 1 • h I II . • SHEDS LESS THAN 150 SQ. FT. SHALL. RE PLACED A MINIMUM OF 30 FEET FROM THE FRONT LOT LINE AND A PLOT PLAN MINIMUM OF 6 FEET FROM SIDES AND REAR LOT LINES. FOR lbdicabe locaticn Additionsw of garage or sary building Well Sewecrage disposal (cesspool) ED ` I I I (lit ................ rear) _ 4 I Name er's Et 5► it I --Abutters AbuI Name If this is a I ' j REAR YARD If this is a Lot# corner lot, ``I� J write in name of street. ........ ..ft. corner lot, �, write in I name of street_ a I .4,‘ 41 SIDE YARD • • /y,_� FlOt75E SIDE YARD • • • • • • • • • • I I ; • SET BA X • • -• ...i. .ft. • 4 i • (lot..................ft. frvnta4e) \ / (NAME OF STREET) / \ rmattrn Supplied by