HomeMy WebLinkAboutBSHD-25-44 application ja,,\• Office Use Only
.«. �. Amount
3,
�,,^
•:��Na`pratE
Permit expires 180 days from
issue date
EXPRESS SHED PERMIT APPLICATION 6C1-1 _2'-tit/
TOWN OF YARMOUTH
Yarmouth Building Department
1 146 Route 28
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS: S I 6G-0-17164
OWNER: NAME
E _ 141e5 PR ("\T.aD[)Rt:S� L / EL.
(O� — /3.21
CONTRACTOR:
-
NAME MAILING ADDRESS I 'I-RECEIVED
EMAIL: -fl e tpi l(l"vv 65i jm4J/s
JUN 0 6 2025
.1:/Residcntial Commercial Est.Cost of Construction S •
BUILDING DEPARTMENT
Home Improvement (ontractor Lie.# Construction Supervisor Lic.# By. ----_
SHED INFORMATION /
/ / f n ✓/
New V Size L %S /0 x H (o Corner Lot: Yes No
Per Town of Yarmouth Zoning Br-Law See 203.5 Note E:
Side and rear t•ard setback~ for accessors buildings containing one hundred filly(150i square feet or less and single story.
.shall he .Six (6; leer in a/I districts. but in no case shall.said accessory buildings he built closer than twelve it 2i feet to any
other building on an adjacent parcel. All_ehetis are required to he located thirty(30)feetJrot t tort front lot line
Replace existing* Size L x I4' 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 be just cause for denial or revocation of my license and for prosecution under M.G.L.Ch.268.Section I.
fo
Applicant's Signature: ` * (/(/-� Date: 6/5//d.7
Owners Signature(or attachment) e lfl /Lt" Date: (0/51o(
1pprosed By: Date-
Building Building Official(or designee(
Zoning District:
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
1 i, Office of Investigations
('''- Lafayette City Center
I
2 Avenue de Lafayette, Boston, MA 02111-1750
�''� 17� www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): E t ) teen_ Wo_S`1-
Address: S 1 9 O rah e 0 L.Gip e.,
City/State/Zip: ' l lti. PJ d''t ) Phone #: 6 0 g 6 5 fi — J23 ,
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. ❑ 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'
9. ❑ Building addition
[No workers' comp. insurance comp. insurance.:
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3. 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 Other SA e(l°
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 line
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: Date:
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 20 Building Department 31:1City/Town Clerk 4.0 Electrical Inspector 5E1'lumbing
Inspector 6.0Other
Contact Person: Phone#:
v..
_
r '
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 kEAR LOT LINES.
FOR LOT It t ( Lis 1
•
rndicate locatlaa of garage or accessory building e1 j/ate'- 11
Additiora with dashed lines --- L'4- 01 (,
sewerag. disposal (ces3spool) 49 Well Lof Welly1 .4 0. 'Ar
14
c103) 1735-Daze Arthur R4' 1 G e ld ,h La nC
e,� (lot ft. ram)
t L r S eta.' 'Q -�
3- Ail Abuu ter's
LotI Abutter's /
Lome � 6� DefX°
i N t# i J •`� - �
t# I I�{,e'
RE
If this is a AR YARD If this is ay;
corner lot, corner lot
ft write in
writename inof street. name of s reet.
' i, ��
4 V a
30
,,LL l
.\ F ,-
SIDE YARD Gat r 75 8/ SIDE YARD
HHOUSEa---�. �. Si (}ar40h LOt a------- UT>
b
1
I
SET BACK
. f.
. 1 I A
I �.
1
•a•
(lot ft. eantage)
•
/ tc7 Goraz 1- -ice
\ /
\ / (NAME OF STREET)
/ Information E ieh �,(� � ash( t)
Supplied by