HomeMy WebLinkAboutBSHD-25-51 - cY!
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PernistaB ortket.,.Only
'0 " r Amount
. _ Permit esptres 1110 days from
issue date
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EXPRESS SHED PERMIT APPLICATION R E C = .' ".� !.:-
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TO11'N OF YARMOU'I 11 ' `
Yarmouth Building Department JUN 27 202 �n�
7 tVV
1146 Route �K _ ��._
BUILDING DEP. Ri
South Yarmouth. MA (12664 By-
41\
coNSrEtt"cnoN ADDRESS: b CI LO 0 1 \ 12‘-.--... SNAki I Gt✓l/VU)__.
.„_____. 02 Co 604
OWNUR ._. \ MUL IC -eArC/I/vii //b o o &.-1-2- vm
•%SMI PM`i\T Sh1)RI SS TLLL �'"?
CONTRACTOR. Q tom!Y1 esr 5oq'' p o?rJ J
ectlf
\mu St sl1 1.6 SI)oRI SS t H I. a
EMAIL: r5 J L� S q �d Q W1�1 , C�'1►h
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tcadcntsai CommercialIt.('o,t of Cbn trucu„n S 31 Div
Home improsement Contractor Lk.* IN'Or Construction Supervisor Lie.* tM 1.A
�/ SHED INFORMATION
!dew Y Size L 1 ( z W. /0 .z H (0 Corner Lot:Yes 17 No
Per Town of 3'armouth Zoning Br-Law Sec 203.5 Note E:
Side and rear yard setbacks fin-oree•ssurt'buildings containing one hundred fi/lt I1 il►t square leer ur less and single stun.
shall he six tit lret in all districts but in no ease shall said cxeessor% buildings he built closer theta tteelt'e i 1=i feet to ant.
other building on an ckhareiu pare el sheds are required to belocated rhin i3tltlea fs:pm ant front lot line
Replace existing* sin L_ _: IF s H .
'The debris will be disposed of at "--re,,...., eX Yt.. .4 , _.
Location of Facility
I declare under perultte.of!serum, the.utcments herein contained arc true and..meet to the hot or my i,non ledge and belief I unJerst.md that am false at►.wcn st
n al he teat cause fiu dental or max:.•k of my license and for prosecution under M r i L.Ch.261t.Section I
Applicant'.Straw' ` is IP Oate (Y 2 G 12s
Owoers Signature rar attachments Date: Ct t 2412.r
Appro%cd By: _ _ Oak
tluiWtng O1Th.ul tordea►gnecl
Zoning District:
Historical District: Yes No
**Conservation review will be required if shed is placed within 1000 of
wetland.200ft from riserfront.or located within a flood zone*
624
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The Commonwealth of Massachusetts
. filigt .
Department of Industrial Accidents
at WE,..z
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of Office of Investigations
t: irer:ii Mt......= rts:
v.... 4 ow Lafayette City Center
N
u , 47 2 Avenue de Lafayette, Boston, MA 02111-1750
4.
www.mass gov/dta
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print LeEibly
Name (Business/Organization/Individual): (lc.\ t c. ‘A. 5
Address: L.) L)0i - ---Qa rN .,. \S-, I' • vv"- A02606, 11.L-
City/State/Zip: Phone # - �__+
Are you an employer? Check the appropriate box: Type of project (required):
I . ❑ I am a employer with 4. 0 I am a general contractor and I
• s have hired the sub-contractors 6. 0 New construction
employees (full and/or part-linnet.
2. 0 I am a sole proprietor or partner- listed on the attached sheet. 7. [] Remodeling
P Pn
ship and have no employees These sub-contractors have 8. [] Demolition
working for me in any capacity. employees and have workers' 9. 0 Building addition
[No workers' comp. insurance comp. Insurance.,
required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3. I am a homeowner doing all work officers have exercised their MO Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12. Roof its
insurance required.] t c. 152, § 1 (4), and we have no
to [No workers' 13.0 Other
comp. insurance required.]
*Any applicant that checks box II 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 subcontractors and state whether or not those entities have
employees. If the sub-contractors have employees, they must provide their workers' comp. policy number.
w - _ . . _ _ -v =
I am an employer that is providing workers' compensation insurance for my employees. Below is the polity 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 S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations ofthe DIA for insurance coverage verification.
_ _ - -- - t - -
I do hereby ce i /= , e pains and penalties of perjury that the information provided above is true and correct.
Signature: � : 1'2GI 11, --
a: ._ ,� -�` Date.
Phone #:
4
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: PermWLtcense #
Issuing Authority (check one):
lOBoard of Health 20 Building Department 31JCIty/Town Clerk 4.0 Electrical inspector 5Eb'lumbin
g
Inspector 6.DOther
Contact Person: Phone #: r
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