HomeMy WebLinkAboutBSHD-25-47- O RECEIVED Office Use Only
O` - Permit;
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,..,•K.« JUN 2 01015 Amount 3 S 1 V
09nov�i E��.
Permit expires 180 days from
BUILDING DEPARTMENT issue date
By'
EXPRESS SHED PERMIT APPLICATION ,, ,.
TOWN OF YARMOUTH L;C I 1 tat/ A-
Yarmouth Building Department I i
1 146 Route 28
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS: / V_7 4 /)
L
OWN f.RIt iCf Zs�i f 4-7 K/��+-�!��_. L 77V 1/$1 49 7 7/. l/
\ME PRESENT ADDRESS • # -v'3 ( 9
CONTRACTOR:
NAME MAILING ADDRESS TEL.u
EMAIL:
Residential Commercial Est.Cost of Construction S � 07l
Home Improvement Contractor Lic.# Construction Supervisor Lic.#
SHED INFORMATION
New- Y Size L x W (7 ' x H Corner Lot: ties No
Per Town o/ Yarmouth loninj By-Law Sec 203.5 Note E:
Side and rear turd sethrh ks her accessory buildings containing one htaulrt'cl fifty t 150) seluart'feel or/es.s and single story,
shall he six (6t lee! in all districts. but in no case shell said accessory buildings he built closer than twelve (12) feet to ant
other building on an adjacent parcel. .1ll sheds art'required to he located thirty (30)feet from am front lot line
Replace existing* Size L x ►f' . II
*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 hest of my knowledge and belief I understand that any false an',erysl
will be just cause for denial or vocation of my license and for prosecution under M.G.L.Ch.268,Section I.
applicant's Signature: iGYXfit/` Date: /2-0/ZJ [/
t'Owners Signature(or attachment) ..6L0+ya- Date: ViZtA Approved By: 6CC Date:
Building Official for designee, _
Zoning District:
Historical District: Yes No
••Conservation review will be required if shed is placed within 100fi of
wetland.200f1 from riverfront,or located within a flood zone**
6 24
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tsar,�,; :,s,
•
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 #
Additions.r�r �atith ica cf garage building
dashed lime ..�
Sewerage dlapcsai (cesspool)
Well co
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I
+ (lot rear)
ar)
-- — -- I
in?
Abutter's I
Name Abutter's
Lot # Name
Lot #
If this is a �7 r REAR YARD
corner lot, b k. If this is a
write in J , ft. corner lot,
name of street. write in
I' name of street.
I . . so.
•o
4 c4
: SIDE YARD
SIDE YARD '
• HOUSE •
•
.
. .
.
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: SET RACE :
.
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. •
.
ft.
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40.
Oat ft. fruitage)
/ / 71 7 tom-- o r a
/ (NAME OF STREET)
............> E..
/ \ Infurmat:1m
/ \ Supplied
SuPpd by
P'. The Commonwealth of Massachusetts
Department of Industrial Accidents
s- Office of Investigations
Lafayette City Center
~' 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): 2.
Address: / `1-- 7 w &---e-k---,Zel
City/State/Zip: v cl \ i2�/— Phone #:
Are you an employ� Check the appropriate box:
Type of project (required):
4. ElI am a general contractor and I
1.0 I am a employer with
employees (full and/or part-time).* have hired the sub-contractors 6. ❑ New construction
listed on the attached sheet. 7. Li Remodeling
2.0 I am a sole proprietor or partner-
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. 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.L'J 1 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
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
I.Homeowners who submit this affidavit indicating they arc 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
Signature:`-' Z der7 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 30City/Town Clerk 4.0 Electrical Inspector 50Plumbing
Inspector 6.DOther
Contact Person: Phone#: