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-7 -I -Zq RECEIVE ® Oftice Use Only
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Cite ��yuPermit#iCA
�A 400..o�s x JUN 29 2022 Amount 35%
BU Permit expires 180 days from
t3y:. NT issue date
EXPRESS SHED PERMIT APPLICATION 7-560
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS: 9 0 6 Ci 7 Z_D L'rt--4-11-)°6t, s c)v4`I'1
OWNER: I 0 11 Vl�pti� I Sc c 77 1 CJ/ G+
NAME) C ' PRESENT ADDRESS TEL. # i
CONTRACTOR: y\V l 5 �l i`C4vw.,f Ng I 1 I7'�'„�'vt 4,4-• S-6 q 6 `c 0 S
NAME MAILING ADDRESS 11 TEL #
wh 4"G✓ ✓n A C)' b`3 1
dential Commercial Est.Cost of Construction$ C�
III
Home Improvement Contractor Lic.# '),„...0 6 3 Construction Supervisor Lic.# (..--S— 1 1 b I ,7
Workman's Compensation Insurance: (check one)
I am the homeowner I am the sole proprietor ve Worker's Compensation Insurance
r
Insurance Company Name: J— .Pwt 'Ivtn, ,./k C-y/v4,y,..,Worker's Comp. Policy# '200 I (, ‘-2
�j SHED INFORMATION (\O E'I�Zo n.e
Nevj \ Size L 1 L/ x W q x H Corner Lot: Yes Nt
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) square feel or less and single story,
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
other building on an adjacent parcel.All sheds are required to be located thirty(30)feet front any front lot line
Replace existing* Size L x W x H
*The debris will be disposed of at: G/`yJ i On 1 �A r1 4i�er-7'r"4ia"r r.-
Location of Facility
I declare under penalties of perjury that the ements h rein contained are true and correct to the best of my knowledge and belief. 1 understand that any false answer(s)
will be just cause for denial or revoc ' of . en: and for prosecution under M.G L.Ch.268,Section 1.
Applicant's Signature: i' ? �------Z_ - ' " Date: ___
Owners Signature(or attachment) Date:
Approved By: ✓ CG Date: _'0'_Z
Building Official esign EMAIL ADDRESS:
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
SHEDS LESS THAN 150 SQ. FT. SHALL.
BE PLACED A MINIMUM OF 30 FEET
FROM THE FRONT LOT LINE AND A
MINIMUM OF 6 FEET FROM SIDES AND
PLOT PLAN REAR LOT LINES.
FOR LOT it
Ibdicate location of garb or accesscxry building
Additions. with dashed .lines
Sewerage disposal (cesspool)
Well ggi
I I
I
.1:› IA -- _.. .
Abutter's
Name Abutter's
Lot# ` Name
Lot#
If this is a REAR YARD
corner lot, If this is a
write in comer lot,
name of street. 1 ft. \.- write in
` -
to ` name of street.
i ' . •C‘
I
4 I
cq
SIDE YARD
HOUSE SIDE YARD
•
•
•
•
•
•
SET SACK •
•
•
ft.
A
T
Got ft. frontage) •
•
(NAME OF STREET)
Information
Supplied by
_tea /
The Commonwealth of Massachusetts
Department of Industrial Accidents
__A!� 1 Congress Street, Suite 100
_�SFI= Boston, MA 02114-2017
tir. ss.•� www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Lezibly
Name (Business/Organization/Individual): IA A /, ,c_c.— P,, 1 1 -, 12.----1.-C�
Address: Li / c' 'I LY f i,-..c._ �g , M U ,) ,-,, ,, LA ,
City/State/Zip: t--i' /�y'l-)-7r,�J YY)( C24, )hone #: '-c 0 (-6f� r 1/ 7
Are you an employer?Check the appropriate box: Type of project (required):
c -I n a employer with employees(full and/or part-time).* 7. _ New construction
2. I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling
any capacity. [No workers'comp. insurance required.]
9. C Demolition
3.E I am a homeowner doing all work myself [No workers'comp. insurance required.]t _
4.C 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 sole 11.E Electrical repairs or additions
proprietors with no employees.
12. Plumbing repairs or additions
5.111 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.C Roof repairs
These sub-contractors have employees and have workers'comp. insurance.1
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. lOther
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: 1,;-y--r ,�G ,
Policy#or Self-ins. Lic. #: -�-.C' i 1.,�
� � 6:7 �Expiration Date: � A
Job Site Address: CY Pi [ ,04 rC.-)_ City/State/Zip: a 1'
Attach a copy of the workers' compensation policy declaration page(showing the policy numbef 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 unde t ains pen fries of perjury that the information provided above is true'and correct.
Signature: Date: .1=". "- Z
---
Phone#: j ('7 5 . 6&0 L, 2 -------
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#:
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Commonwealth of Massachusetts
`r� Division of Professional Licensure
Board of Building Regulations and Standards
Con4V 'Supervisor
Expires : 11 /.19/2024
R `SEI.. T H AMEN �., �, �r.
3811 MAIN STREET
BREWSTER02631
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