HomeMy WebLinkAboutBSHD-25-24 application / ir YA,�Oi . „S
Office Use Only
3 C i Permit+! LVAI
50
° �'
.tC' �....« : �a Amount3506
ny. .. ,, r Permit expires 180 days from
issue date
4471
EXPRESS SHED PERMIT APPLICATION i 4 „ 3 ;
TOWN OF YARMOUTH e IYarmouth Building Department APR 18 2025
1 146 Route 28
South Yarmouth, MA 02664 ___________I 1
D BUILDING E ARIENT
(508) 398-2231 Ext. 12616�/� ElyJ
CONSTRUCTION ADDRESS: 5- _ _Ric-5_-_ C -" c41I /v
OAk''sNER: PCIVLIotit. v T I 4 4 I t`L5 50 LSr—6
NAME PRESI-NT.ADDRESS TEL. is
CONTRACTOR:
NAME NI AILING:ADDRESS TEL.a
EMAIL: 12.-01),I-h IAL i Z j�3 9'Jv y 0 (-toL' ' W .40
cadential Commercial Est.Cost of Construction S
Monte Intprosement Contractor Lic.# Construction Supervisor I.ie.#
SHED INFORMATION /
New '( Size L 11 W x H Corner Lot: ties No ✓
Per Town of Yarmouth Loning Br-Law Sec 203.5 Note E:
Side and rear card setbacks for accessory hui/dings containing one htll dyed filly t150i square feet or less anti single story,
shall he sir (61 feet in all districts. hut in no case.shall said accessory buildings he built closer than twelve i 12) feet to ant'
other building on an adjacent parcel. All sheds are required to he located thirty(30t fectJroin antiron!lot line
Replace existing* Size L_ _x It' x H ��,Q[��
*The debris will he dispose,!of at: Ai d/e y__ c,=^" C.o ��
✓ 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 denial or revocation of my license and for prosecution under M.G.L.Ch.268.Section I.
Applicant's Signature- (���� �?�/' Date.
Owners Signature(or attachment) ' 1/E v� \_/ r r '�1 1 Date:
Approved By: Date:
Building Official for designee,
Zoning District:
Historical District: Yes No
**Conservation review will be required if shed is placed within I OOft of
wetland.20011 from riverfront,or located within a flood zone**
6.24
P' The Commonwealth of Massachusetts
Department of Industrial Accidents
1 10 Office of Investigations
(, Lafayette City Center
kw
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): / l.. r I ' . Le ke _ , ,
)�K�
Address: -Z 5 % ).-FCR kc (IV 'N--QJ/ inUali 4'i /1' `ViiCalq
City/State/Zip: Phone #:
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 6. ❑ New construction
employees (full and/or part-time).* have hired the sub contractors
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.'
rewired.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.LC�-'i am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.] t c. 152, §1(4),and we have no
employees. [No workers' 13.0 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 herebyiertify under the pains and enalties of perjury that the information provided above is true and correct.
Signature: I`Q C0L LQ '1 a 1 frlA Date: - V 2S
Phone#: c V C6C I cb 2-Z.?
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 3ElCity/Town Clerk 4.0 Electrical Inspector 5llumbing
Inspector 6.0Other
Contact Person: Phone#:
- R y ---- 3v --.. -
• Fro 1) 1 wch /j), L 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 t
Indicate location at garage or accessory building
Additions with dashed lines ---
Sewerage disposal (cesspool) 69
lieu
I I
I (lot ft. rear) I
1>
Abutter's Abutter's
Name I Tio Name
Lot# I 3P Lot it
If this is a REAR YARD - If this a
lot,
lot, corner lot,
write in ft. write in
name of street. I 4 34) name of street.
a
8
b
4 im cz
SIDE YARD SIDE YARD
HOUSE
d----x� c 4-----rgi>
I
SET BACE
ft
1
a
(lot ft. frontage) .
/\ / Jl lj`�. r I (Milt l
/ (NAME OF STREET)
/ Information
/ \. Supplied by