HomeMy WebLinkAboutImage_002.pdf - BSHD-23-101 28887Ollice t sc (hl\
c{4au*
3{.ID
Pernrt cxpires 180 days liom
EXPRESS SHED PERMIT APPLICA
TOWN OF YARMOLITH
Yarmouth Building Department
ll46 Route 28
South Yarmouth, MA 02664
(508) 398-22; I Exr. l26l
CO\STRT'('TIO\ ADDRESS:&frgbql,L% S_W.tzA_A_
OU NER I{l\l I FN I)IFI }
I.'ONTR.\CT()I{
D Rcsidenrial
N \NII IUAILINC ADDR!-SS TET 1
"{ommercial
Est Cost ofConstruction $t0a0. tl "/
Home lmprovem€nt Contractor Lic. # Construction Supervisor Lic. #
Workman's Compensation lnsurancc. {chcck one)
I am the hontco\rncr I anl the solc proprictor I hlr c \\'orlrr'. ( ompcnsllion In,uruee
lnsurancc Cornpanv Namc
SHED INI.O Ri\IATI()N
J(eu Size I- /O xW /A ,H /O Cornerlot: yes xoy'
Per Tovn ol I arnur lh Z,oniu:t B '-Luw, Sat 20.1.5 N a ESide und reor .ttud sctb
thull hc'si.r (6t li,ct iu ul
rthtr btrihling tm uu ulj
\,\.orkcr.s Comp. polic) c
,r,ks .for ucces.rort huihlings uutltrirting onc htuth.ct! /iftt. ( l5di.\trid\, hut irt rttt t tttr: .thull sttid u<.<.c.sutn, httiliin
turc cl. .1ll :hais ttt
0t squt c laet rtr lt',t.t uul .ringlc slort
gs he huilt c.lostr thut lr'.eltc ( t2) latt nr unt
lt !1ilel ttt bt loc.ttt ' t30)fe 'a 4t lot lintt.r'Ji'r
Replace existing * 7@
'l llr dehfls $ tll he dr\posed ol at
Appftcanr-s Srgnature
O$ nrrs Sipnatur( (or : rArhmenrl
Sizc L II,
m
r{tinn of tacitih
I I)ale
l)llc:
I)xl.
oApproved 8r
Building ( )llr $al (or dcsisnee)tiIIAIL ADDRESS
EIVED
DEC 1i 2023
PARTMENTBUILDING OE
llistorical Dislricr: yes No Flood plain Zone: yes
Water Resource Pror.ction Dislrict: Wthin 100 li. ofWerlands. i *ryes No* * *Not", ionr..n utiol revie\ requircd ifrrirhi" [e;ft. orw.]uona.
No
Zoning District
/"//,16> ft,bcu7 4.a L"es .d,..4
ill
\\'orkers,Compensati
TO
The Co mmonwealth oJl Massach usetrs
D ep artme nt of I n d ustrial A cc i d e nts
1 Congress Street, Suite 100
Boston, MA 02114-2017
www. mass. gov/dia
ou Insurance Affi dsvit: Bqilders/Contractors/EIe
BE FILED WITH THE PERMITTINC ALTTHORITY
ctricians/Plum bers.
ntl tion
Name (BushesVOrganizarion/lsdividual):
se Print
Address:
City/State/Zip:
5/
gPhone #:
I
l I I am a cmployer with _.mployees (fiill and/or pan_tim.)..
I am a sole propJicror or paft)ership and havc no employees wo.kin8 for me irany capacity. [No workers'cornp. rnsr:rance req!:lrco ]
I am a homcowner dorng all work mysclf. [No workers' comp insurancc requr.d ] r
d,aro a horneowncr aad will be hiring contractors to conduc! all work on m
l
4
ensure that all contracbas cithcr havc workcrs,compcnsahoo msurance or are solepropridors wth no cmployces
y propcfty I will
I am a gencral conE-actor and I havc hir.d th. sub_conE-actoir lrslcd on rhe altachcd shccrThcsc sub-contractgrs havc cmployees and have *ork"rs, comp i;;;;;* - -
Wc arc a corporalloD alrd lts officcrs have cxErcEEd their righr ofexempdonI i2. S I (4), and w. havc no employecs. p.ro *ort.r.' .o.pl i*ur-i. [!ii:pcr MGL c
red l
'any applicanr that checks box #l must also fill o,rr thc section=below showing thcir worian compcnsation pol icy infomarion_i Hordeo.,ir'ne6 who submit thls affidavi! lndrcating hey are dotng dl work and thcn hirc outside cootracrors mus! submtt a new affidavll indtcathg such.aContractors rhat chcck lhis box rnust anachcd ar additional shcet showing thc nama ofthe sub-conllactors and state whetler or not thosc enotics haveernployees. If thc sirb-conE-actors have cmployces,thev
Type of project (required)
Z. ffiNew construcrion
8.
9.
t0
II
),2
13
l4
Remodeling
Demolitior
Buildiog addition
Electrical repaiE or additions
Piumbing repairs or additions
Roofrepairs
Other
I. am an employer thqt is proyid.int workers,inlfomation-
Insuraace Company Name:
lnust providc thcrr workcrs' ;omp. pohcy nuhbcr
compensq.tion insurance for my emplolees. Below is the policy atd job site
Policy # or Self-ins. Lic. #
Job Site Address:
Attach a copy of .City/StateziP:-
Fa,uretosecurecoverase",,"oJ:'0";T;'fi:,-...:',f?;;::::L"_1'#;:'.";::::::ffin,;,:.fi1.i,,o::r.;,
and'/or one'year imprisonment, ai well as ciul p.n"lri", l" ii" ro* of a srop wonxbnngn ania fine of up to $250.00 a
"do,li[]it#"uT;lator'
A copv ortlit tt.t...ni ruf-i.'i"*.a"i . ,r,,e office or rnvest[^,i"rr'"r,rr. ore for insurance
I do herefu c undet tl,and penalties of perjury thd.t the information provided above is true and correct.
Date
PermiULicense #
4. Electrical lnspector 5. plumbing Inspector
Phooe #:
Offtcial use onty. Do not |ertte in th$ area, to be completed by city or town officia!.
Department 3. City/Town Clerk
Contact Person:
Issuing Autho rity (circle one):
l. Slill"rr.",,h 2. Buirding
Ar. you an rmploy.r? Ch.ck lhe appropriate bor:
: L_.1
a
I
trI
T
Ttr
City or Town: