HomeMy WebLinkAboutApplication$ffi,
EXPRESS SHED PERMIT
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SHEDS LESS TIIAN 150 SQ FT SIIALL
BE PLACED A MINIMW OF 30 TEET
FROU TIIE FRONT LOT LINE AND A
MINIUIJM OF 6 FEET FROM SIDES AND
REAR LOT LINES
TOWN OF YARMOTJTH
Yarmouth Building Departmcnt
I 146 Route 28
South Yarmouth, MA 02664
(s08) 398-223t Ext. l26l
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APPLICAT kv"S PitW
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ASSESSOR'S INI'ORMAI ION
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CONTRACTOR
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IEL T
TEL' i
Est. Cost ofconstruction g 2 O 'o AVftesi,lenrral D Commercial
Home lmprovcment Contractor Lic. #
WorkmalX Compcnsatlon lnsurar!ce (check one)y' I am the homeorrner I am the sole proprietor
Insurancc Conrpanr Name:
adL"JI]AVE
NAME
NT ADDRESS
AILING ADDRESSv
CoIstruction Supervisor Lic. #
I hare Wqllsr'5 (6rnpensation Insu.ance
Worker's Contp. polic)#
S ED INT'O A'N
Nerv
-
size L(. x Lt. l7 xa 4
I,,
'er Tot Iu Low ec2 E:
SiLlc tnd recu selbacks /or uccessor.y buildings less than 150in no case built closer than t 2 le
Replace cxisting* _ Size I
'The d.bfls $rlt b. d6pos€d ofat
el lo qfi)' olher buildinu.
Corner Lot: Yes ffo Y-r\
square Jeet and single story, sha be 6 feet in all disu.icts, but
Location oI facilirr.-
I declu. [nder prnalncs ot pcrjUrv thnt statemenB herein containad arc uue and corrcct to lhe bcst olm!,kno\\ledge and belref I undcrstand tlta! an, falsc ans$cr{s)\rllheJtlsl carru ti)r dcnlill(1r rc!(,ofnU lrcensc and for prosecunon undcr Nl C l. Ch 26S. Scction I
fpptrc'rr s srgn,urc
Datc
EI\I AII ADDIIFSS c tZooing Dlstricl
No Flood Plain Zonc: yes
lricr: Wirhin 100 n. oflt,crlands: r**
Yes Noic$ rcquircd if $irhin t00 ft. ot'U,etlands
Dnlr
F.d'D ?\
J., r:Orrnrrs SigIlture (or ittrclt l,
Approvcd B)
llu Llding ()flicial (or dcsigree)
14 rEgmul,(otvr
I listorical Dinric(: ycs
U'atcr Resource Protcction DisYes No**tNote: Cooser\ation r!\
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lrtlup,
Name (Blripcsyoryinjzsrion/trdividud) :
Address:A
CitylStxetZip:,
Anl rpplic.rt thst drck! box rl rDl&dso 6tl otn t|c
The Co ntaonw eatth of Massachus&
Dep artment of Industr ial AccidentsI Congress Sted, Saite 100
Boston, llA 02il4-2017
Phone #: (n o-113-4 1at
rcctioo bclor drowing trir *slcrr'co(oparrldion polioy irfofErtiorL
llbrters' compensadon Insu-"*H;m';'Jl'"faoo** *rectricir*nrum bersTO BE FTLED WTTH TEE PERMITTINC AUTHORITY.
t ItonEowrr.f! q/ho sub! t his !fidavit irdicating 6sy &! doilg sI wo* rrd tgr hir! orGidc coob8tcr rEt$ $bmit a osw .ftda/n indisirE sucL&Corracol! ttat chcct rhir bor mu*lllclEd so lddhional sh€rt *towing ttrc oarrc ofthc sub<ontrctors and sanc rrlpthcr or oot ttt@ cotiti.s bvc
Ar! yoq l! loplotrr? Cf,Gck 6a rDproprht! bor:
t.! t lra r employcr wi6 rmployr6 (full rtrdor parr-ttrr).t
2.f) I am a solc pogrilbr or p!ftErship ud havc no lrsplqy.rs wsrkiDg fB rm inlry clFrity. [No lr.ortcn' conrp. irrurau rtquirri,_]
-
3,! I ro r hcnco'rarr doiog rI e,ort Eryrclc [No wortr.!. cor[p, ilsrrrlrr rrquird] r
r.ft_.r r r,or*,rr- rld w l.bc hiring crG6n to crndrrt rll wo* q! ry FlFty, I wil- tBrrl itrd ![ cooEeE ?it!r ttrvr u.otus' coEpacdio tnsnara orG ilc '
ptrprie! wi6 no splolccr.
5.[ I ur a gl(Irlt coltrru.Dd I tEer biild th. erb.cqt&E lkcd oo &. echd dlaTh!!s trEcortlrb! hava c[pl€r!a! slrd t!v! vo*!r!' coop. irqu.rroci -
6.[ W_c rrc a corpoltioo ut b od6ccfl havc rx.rcirsd thcb rigt* ofcxcoptioa pcr MGL c.152, I l(a), arl rre h&c rD curployGcs. [No urorbn' ".ogi ioo-r". i.a*ia.1
lf dlc suEconE&tr! hsv!
I an an emplolq that
WormdaL
try murt providc trcir vo*cr:'
b providhtg vorken, compotadon |orsuranrce for nzy anptoyea. Be.low ts kepoticl ondJob site
lnsuraucc Company Namc:
Poliry # or Sclf-ins. Lic. #:Expiration Dstr:
'.oitt-*^'*t- ,, .. , . ciglstucrZip:-.ltt.o"*pyortu@ege(showingthepolicyuumberrldcxPirrtiond8tc),
Failurc b secure. coverage 8s requtad uuder MGL c. 152, $25A is a criminal violaion puuislnble by a fiac up to $l,500.00ard/or one'year imPrisonEeut, as wcll as civil pcnahies is the fonn of a STOP WORKbRDER and a fue of up b $250.00 aday ag';n51 69 ,;olaor' A copy of ttis statrocnt Eey bc fonruded b the ofEcc of hvestigatious of thc DIA for insurancccovcrage verifioatiou
I do h*eby cerdly the pains and ol pqiury thdt the ir{otmariofl provided dbove is true snd corrcct
9
Offrcial use only. Do not wrire in this oco, to be ompldd bl city or tosn olfidal
l. Borrd of Ecalt} 2" Buildiug Dcpertu.Bt 3, City/TowD ClGrk 4. Etcctricrl Inrpcctor 5. Plumbing luspcctor
5. Othcr
Permlt/Liccn!e #Clty or Town:
x Ka C
.mployres.comp. policy Dl8bcr.
Type of project (requireQ:
7. ffNcw constructiou
E.ffRemoacting
9. E Dcmolitioo
l0 [ Buildiag additiou
I I . E Elc€ticsl r.pain or additioos
12. fl Plumbing npain or additions
13. ! Roofrcpairs
14.f-'l od*r
CoEt ct PcEoD:_ phoac #:
PLOT PI.AII
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Lot #
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Abutter's
Lol #
l{ame
It thl3 l. .comor lot,wrlta lnnrms of street.
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