HomeMy WebLinkAboutBSHD-25-35 application Of' ' ,4j Office t k.e Only
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EXPRESS SHED PERMIT APPLICATION5 � �3,5
TOWN OF YARMOUTH
Yarmouth Building Department RECEIVED
1 146 Route 28
South Yarmouth, MA 02664
(.508) 398-2231 Ext. 1261 MAY 13 202
CONSTRUCT ION aDDRk:SS: 51--_.O40 , - BUILDING DEPARTMENT
`j a By:
()WNFR: /`totiti, Gci( 1 f ` 11?i 5 l `Jfirepri to jtt- ( 2 i '/arrywki - .j r . u
N\\II) PRI SI \T \DDRI SS 1 fa. , J
CONTRACTOR: line 1-k )C
NAME \I VLING \I)t)RLSS TEL
EMAIL: a:-I0(e9WY1.;1• Com
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Residential Commercial F,t.Cost of Construction S
Home Iinprov ement Contractor Lic.# Construction Supervisor Lie.# _
SHED INFORMATION
Ness X Size L /6- x SS' IC x H Corner Lot: l'esy No _
f'er 79n0 r) )Nrstimrth /fN)itt,flt.-Law Set 'lP .i 34)1 L
Replace existing* Size L x n x H
*The dehri.wilt t-i dipod of at 6itle6dAeoL .. oafix. ,_, ifdiba�
Location of I' lilt
I declare under penalties of perturs that the statements herein contained are true and correct to the hest of ins know ledge and belief. I understand that am, false anso er,s I
w ill he Just cause for denial or restoration of my license and!Or prosecution under NI t i 1. ('h 2b5.Section I
Applicant's Signature t u D:ur ,5//3/::J
Owners Signature I attachment) Date:
\ppm f ed Bs Dane
Building Official for deli heel
Zoning District:
Historical District: Yes No
**Conservation rev icw will he required if shed is placed within 10011 of
wetland.20011 from riverfront.or located within a flood/one**
.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Lafayette City Center
gal 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): (Vli ..i,) t :iG t I ve.o
Address: J I OC' = ( -C-p-y
City/State/Zip: Y 1 ft--1,'' r ) iACIL - Phone#: �' / - 710 Are you an employer?Check the appropriate box: Type of project(required):
4. I am a general contractor and I
1.❑ I am a employer with ❑ 6. ❑ Nev construction
employees (full and/or part-time).* have hired the sub contractors
listed on the attached sheet. 7. Li Remodeling
2.❑ 1 am a sole proprietor or partner
ship and have no employees These sub-contractors have 8. CIDemolition
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 10.0 Electrical repairs or additions
3. RI 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.] + 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 tine
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.
Signature G/ Jl. Date:
Phone.+: '` ios
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):
1❑Board of Health 211 Building Department 3❑City/Town Clerk 4.0 Electrical Inspector 5; lumbing
Inspector 6.0Other
Contact Person: Phone#:
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J t 48. '- 2. Zone R-40
j front Yard Setback: 30' i
'74 Homers Dock Rd. I p Side Void Stttwck; 20' {t
Deed e& 11515 i _ f 4 Rex Yard Sstboak: 20'
Pg. 254 � 7'x t 3' I Max. Bolding Cow age 25R
Pool I ' tut tlne SuAdlne Covesear
I hereby certify that the structures tt1 J 073 s.l./23 857 s.l. tZ,Bft
shown hereon are booted j' j' ) i c exist on the ground W -JS2 ""`+r"�" 1JJ 1 1 3. 3truetuns do not roll b a special I
it.
5 """""" a5 r { $ I dead hazard zone a shown on 1
t1 1 f F.t,M,A. FRM map Na 2500100579J
kcharts. 7/1ll/2ot,
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DonikR T Poole Date 1 1 9 1 4. %ratio *Atom shown from goord o! Ik
P L$,1r32RE2 2 1 i Mullin -As-Built'Plane
1 �35.7'•-_ , l
0°i �._ Lot 48 I 1
Area = -,
Coto "`' ---•�_ _ _ 23,857t Sq.Ft. 36.5
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No. 3260z or 0.55 Acres `
'ep,,` C r Site Plan
` � �88 ttam.rs Dank Rd. syst.. -- e ' #51 Dartmoor Way
Deed 8k 34090 . tg t
CO
11 Yarmouth Port, MA
320 Pnd. ,n —_, - 1 i-------. -
i V prepared for
IQ I ?-1 Ner,39.23.W ( Mo jtaba M. & Gail A. Amini
o� E Rt"'Qs, j E $ I r 30'°°' t Deed Book 28052 Page 134
i ;,,,�3l 1 ai I t Lot 48, Plan Bk. 214 Pg, 117
-=I 043 Dartmoor tra, 'f a Scale: 1" = 30' September 30, 2024
A �rj D.e
pa`:9. J4weo7 o!s #496001
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