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EXPRESS SHED PERMIT APPLICAT C E p V E D
TOWN OF YARMOUTH
Yarmouth Building Department FJUL 2 8 2022
1146 Route 28
South Yarmouth, MA 02664 BUILDING De4aRTR4ENT
(508) 398-2231 Ext. 1261 Bv._
CONSTRUCTION ADDRESS: 3 2 2Of � C'Q� U.„.ff-s-1-- ca.-kb
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OWNER: NNUll C,(\- t'1�M �Cc(o �72 eec i ? L). `lo i"se I.k k
NAME PRESENT�• ADDRESS TEL. #. �f r ^ r
CONTRACTOR: AdeirscIn Cc)j' �OS0' ,� Q fit} (� / (�10t (`+
NAME MAILING ADDRESS TEL.# `50 `�q is ' .c.' 4 "I
)102.esidential 0Commercial Est.Cost of Construction$ ( ,30 0
Home Improvement Contractor Lic.# Construction Supervisor Lie.#
Workman's Compensation Insurance: (check one)
9.1..am the homeowner I am the sole proprietor I have Worker's Compensation Insurance
Insurance Company Name:, Worker's Comp.Policy#
0
SHED INFORMATION
New l) Size L I x W 1 x H 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)square feet 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: Yailli L(Y,
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 r revocation o my license and for pr ecution under M.G.L.Ch.268,Section 1.
Applicant's Signature: (-�` C' _._ Date: C. 29" 2.0-e.- -
Owners Signature(or attachment) '-'64e6,26Date: z$ l ��hZe,�/ �
Approved By: Date: . .2.
Building Official i EMAIL ADD
Zoning District:
Historical District: Yest No Flood Plain Zone: Yes x,\10
Water Resource Protection District: Within 100 ft.of Wetlands:****
Yes No , Yes s No
***Mote:ConsePation review required if within 100 ft.orWetlands
3/22
The Commonwealth of Massachusetts
Department oflndustrialAccidents
1 Congress Street, Suite 100
f r' Boston, MA 02114-2017
_ www.mass.gov/dia
Y�orkers' •
Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): 1 " ► t y
Address: ZJZ P, , Lai p4 d (A ie5; VQA- \1 2 7 (VIA G _G ?
City/State/Zip: Phone#: Z 4 9,3 g
Are you an employer?Check the appropriate box: Typ�of project(required):
1.E I am a employer with employees(full and/or part-time).* 7. ,k h -w construction
2.0 I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling
any capacity.[No workers'comp.insurance required.]
9. ❑ Demolition
3. I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
10 [] Building addition
4.0I 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.n Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. L .13.E Roof repairs
These sub-contractors have employees and have workers'comp.insurance.:
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q Other
152,§I(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 suck
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 S250.00 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 ains and penalties of perjury that the information provided above is true'and correct.
ci ' - c�...C' �
Signature: --
� C�P Date: (
Phone#: c Z c`-f'
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
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Sewerage disposal: (c(cesspool)
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