HomeMy WebLinkAboutBSHD-25-23 applicaiton ¢�O.i.ii1,1 R`tr ! 1 LT i D Office Use Only
�� O Permit# e �ci b
�^.,;,T: s!$ APR 15 2025 t Amount J '
-J BUILDING DEPARTMENT Permit expires 180 days from
I-BY.
issue date
EXPRESS SHED PERMIT APPLICATIONHP-
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS: /V /` i 1L4\..
OWNER: t t°6"1 - VIAY‘exl 11 r ew Larva- W. , 5/5-1/28—/oe `Jr
NAME PRESENT ADDRESS ( TEL. #
CONTRACTOR:
NAME MAILING ADDRESS TEL.#
AResidential Commercial Est.Cost of Construction$ -6-1)0 • V
Home Improvement Contractor Lic.# Construction Supervisor Lic.# •
Workman's Compensation Insurance: (check one)
I am the homeowner I am the sole proprietor I have Worker's Compensation Insurance
Insurance Company Name: - Worker's Comp.Policy# -.
,, SHED INFORMATION
New X Size L ig x W 4 65! x H Corner Lot: Yes No
• Per Town of Yarmouth Zoning By-Law Sec 203.5 Note E:
Side and rear yard setbacks for ac•c•e.ssory buildings containing one hundred fifty (150)square jeet 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 out .
other building on an adjacent parcel. All sheds are required to be located thirty(30)feet from any front lot line
Replace existing* Size L x W x H ' U
. *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 be just cause for denialal or revocation of my licenseand for prosecution under M.G.L.Ch.268,Section 1.
Applicant's Signature. V`i.'N V I, �",,^p�i/- Date:
Owners Signature(or attachment) Date:
Approved By: Date:
Building Official(or designee) EMAIL ADDRESS:
Zoning District: - ,•
Historical District: Yes € Flood Plain Zone: Yes ( o)
Water Resource Protection District: Within 100 ft.of Wetlands:*** •
Yes (IQo'') No
***Note:Conservati review required if within 10 ft.of Wetlands
3/22
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The Commonwealth of Massachusetts
=;rim /, Department of Industrial Accidents
=gel= 1 Congress Street, Suite 100
Boston, MA 02114-2017
I www.mass.gov/dia
uor
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Lezibly
Name (Business/Organization/Individual): j >�' , �d ot6
Address: / ; 1 ( t L4-1
City/State/Zip: Cc. e4A- Phone #: 5a, - 29V.-7 i
Are you an employer?Check the appropriate box: Type of project(required):
l._I am a employer with employees(full and/or part-time).* 7. New construction
2.❑I am a sole proprietor or partnership and have no employees working for me in 8. E Remodeling
any capacity. [No workers'comp. insurance required.]
9. C Demolition
3.[31 I am a homeowner doing all work myself. [No workers'comp. insurance required.]t —
10 Building addition
4.❑I 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.E Electrical repairs or additions
proprietors with no employees. 12. Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.—ROOF repairs
These sub-contractors have employees and have workers'comp. insurance.1 —
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c.
14.7Other $itEh
152,§1(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.
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 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 $250.00 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 pains and penalties of perjury that the information provided above is true and correct.
Signature: - _ ( zA r, Date: t�'/75_ 2 6-2 r
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 (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone#:
SHEDS LESS THAN 150 SQ. 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 1t
•
Indicate lacatian of garage as accessory building
Additions- with dashed lines ---
Sewerage disposal (cesspool) 69
Well ag
(l,ot ft. sear) I
Abutter's ) Abutter's
Name Name
Lot# (✓ Lot#
REAR YARD — If this is a
If this is a corner lot,
corner lot, Li write in
write in ft.
name of street. name of street.
I -
•O
SIDE YARD HOUSE SIDE YARD
SET HACK
' ft.
.
(lot ft. frrntage)
•
/ Air S�}� 1ii 3 C
� \ /
\ / (NAME OF STREET)
/ Infarmatirn
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