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Home My WebLink AboutBSHD-24-79 " iY RECEIVE Ofr_ 1 D Office Use Only .(:);_- —_,-Aji LIUL 29 20211 -,'t- ..�� • ,, . Amount W.00 .,..!,,pc„,,,,... BUILDING DEPARTMENT .. Permit expires 180 days from By issue date EXPRESS SHED PERMIT APPLICATION TOWN OF YARMOUTH • Yarmouth Building Department 54�' `t---ff 1 146 Route 28 South Yarmouth, MA 02664 2 (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: 5 ✓ Col burnt Pa^t-L, w. y arm 60 , MA 02c�'1'� OWNER: 1—M\O A3 5k Spmeu€PRF.SENT R SSColbuYne Path �= y oag NAMECONTRACTOR: `J /� NAME MAILING ADDRESS TEL.» EMAIL:dar 1•t hk11 avj C 9 t i . co rn J Residential -'Commercial Attst.Cost of Construction S l 0C) Home Improvement Contractor Lic.# Construction Supervisor Lic.# X ID SHED INFORMATION ANew Size L x W x H Corner Lot: Yes No Y Per Town of Yarmouth Zoninx By-Law Sec 203.5 Note E: Side and rear lard setbacks for accessory buildings containing one hundred f f y (150)square feet or less and single story. shall be six (6)feet in all districts. but in no case shall said accessory buildings he built closer than twelve (12)feet to any other building on aii adjacent parcel. All sheds are required to be located thirty(30)feet from anyfront lot line Replace existing* Size L x II' x H *The debris will be disposed of at: 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 he just cause for denial or revocation of my license and for prosecution under M.G.L.Ch.268.Section I. Applicant's Signature: - _ Date: AOwners Signature(or attachment) ` Date: ' �'9 • 24 Approved BY ..../# Date: !_. AZ / - Building Official(or designee) Zoning District:_ 1 Historical District: Yes No **Conservation review will be required if shed is placed within I OOft of wetland.200ft from riverfront.or located within a flood zone** 6 24 ` The Commonwealth of Massachusetts Department of Industrial Accidents Cl - Office of Investigations t Lafayette City Center ' , , 2 Avenue de Lafayette, Boston, MA 02111-1750 51 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): WO,V9 sprag,te Address: 5 3 CDC cr)u rae PQth City/State/Zip: N. \I Q(mo ukV 11 O2Ge1ihone #: J1 c -C)l - <4 0a Are you an employer? Check the appropriate box: Type of project (required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. n New construction listed on the attached sheet. 7. ❑ Remodeling 2.❑ I am a sole proprietor or partner- ship and have no employees These sub contractors have 8. n Demolition workingfor me in anycapacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.+ required.])., 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3. I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.n Other 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: 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 Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. x/I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. \ 1k Signatur4 ,QC?A ci �,•'5:?)704 C ' Date: —7- 2 . 2_-L-1 Phone#: J \ U- ci. L-( O o2 q Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority(check one): 10Board of Health 21:Building Department 31:City/Town Clerk 4.0 Electrical Inspector 50Plumbing Inspector 6.0Other Contact Person: Phone#: • SHEDS LESS THAN 150 SO.FT.SHALL RE 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 # Indicate ]oCaticn of garage or accessory building Addition with dashed lines sewerage disposal (cesspool) ED Weil(j/I� I licit I ft. rear) 4 _ Abutter's Name G ( Abutter's Lot# ' Name If this is a _ Lot# corner lot, �� REAR YARD If this is a write in R. corner lot, name of street. I write in (' name of street. I . s' v q SIDE YARD SIDE DS YARD • •a---. ,.Er,. 1----- • • • • • • • • • SET BALE • • • i ft • I a 30 licit ft. frca ) \ / / 53 Coleurne Pc th (NAME OF STREET) / \ Informatirn / \ • Supplied by