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issue date
EXPRESS SHED PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS: //7 N077tAJC//- 4q Avg- y
OWNER: -7EFA-4Ex r/ ', V,7C7S, 7�t/ 330 ?"//e)
.NAME / PRESENT ADDRESS TEL. a
CONTRACTOR:
NAME `I VLING ADDRESS TEL.#
EMAIL (..-` V F�-g___Cl 31... 'op-f 2, c____d in
Residential c-onunercial Est.Cost of Construction S (5-000.vv
Home Intpro%cmcnt( oniractor Lie.# - Construction Supervisor Lic.#
/ SHED INFORMATION
New V Size L /y v ‘N /2,, x II Corner Lot: Yes NoYN
Per Town of Yarmouth Zoning Bi.-Law See 203.5 Note E:
Side and rear t'cu'd setbacks for accessory buildings containing one hundred fill (150i square feet or•less and single story.
shall he six t6) feet in all districts. but in no case shall said accessory buildings he built closer than to else t 12I feel to ant,
other building on an adjacent parcel. All sheds are required to he located thirty OW feet from any front lot line
Replace existing* Size L x it' x H
ic.:Z.._le debris will be disposed of at: To
•
Loc on of Facility-
!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 answeris)
will he just cause for denial or revocation of my license and!Or prosecution under M.G.L.Ch.268.Section I.
Apiiik 's S'irr t e: Date: �-
T
eh� gnaw,: or attachment)
Date: b/- 7:2-,5
a
RE
Approsed By: _ Date:
Building Official tor designee) C
• Zoning District: CI v E D
Historical District: Yes No JUN 04 2025
*'Conservation review will be required if shed is placed within 100fi of
wetland,200fi from riverfront,or located within a flood zone" By. DI •
PAR MENT
6.24
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 11'
•
Indicate location of garage cr accessory building
Additions with dashed lines ---
Sewerage disposal (cesspool) ED
Well aigi
I
(lOt ft. reacr) `
Abutter's Abutter'sName
Name 1�
Lot# Lot#
If this is a REAR YARD If this is a
corner lot, corner lot,
write in i5c. ...... ••ft. write in
name of street. /7- I • name of street.
1 'o
cd
SIDE YARD HOUSESIDE YARD
SET BACK
ft.
•
•
(lot. ft. frontage)
•
(NAME OF STREET)
/ Inf rmat 1rr
Supplied by
. ' The Commonwealth of Massachusetts
Department of Industrial Accidents
t i Office of Investigations
`� c..i
Lafayette City Center
a 7 2 Avenue de Lafayette, Boston, MA 02111-1750
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address: / //7 A". 77 /VG/I fr' 1 fa
City/State/Zip: r Phone #:-
Are you an employer? Check the appropriate box: Type of project (required):
l.❑ 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. ❑ 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. ❑ Demolition
workingfor me in anycapacity. employees and have workers'
P Y 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
officers have exercised their 11.0Plumbingrepairs or additions
3. I am a homeowner doing all work P
self.6,. 1,
[No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] t c. 152, §I(4), and we have no
employees. [No workers' 13.❑ 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.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
r Signs 2:�,!/z---- Date: °2/ /-2--6-'
Phone#:
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 2❑Building Department 31:City/Town Clerk 4.0 Electrical Inspector 50Plumbing
Inspector 6.DOther
Contact Person: Phone#: