HomeMy WebLinkAboutBSHD-25-67- „'” ` s c.. Office Use Only
r:i Permita
k' -�'. 6 2025 Amount 33 v
O.. ri%)
Permit expires 180 days from
BUILDINM AEtARTMENT itf[ j issue date
EXPRESS SHED PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1 146 Route 28
South Yarmouth, MA 02664
('508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS: otFrahm�es Men 4W 1.----
f - r
OWNER: ftl 161ael .111 111e / QO traocea_AectIRCI7W-1 '- 33,91 t,..-••"*"
NNW: PRESENT ADDRESS TEL. u
CONTRACTOR:
^
NAME �+,,, , MAILING ADDRESS rEL.#
EMAIL: 01001eV -2024r tem t
V Rc.1,irnu:tl -Commercial Est.Cost of Construction S ydo . ,,
[Ionic Improvement ( (infractor I.ic. k Construction Supervisor Lic.#
SHED INFORMATION
New X , Size L )? x w 8 x H If Corner Lot: Yes No Y.
Per Town of Yarmouth Zoning BE-Law See 203.5 Note E:
Side and rear yard setbacks for ac•ces.sorl buildings containing one hundred filly(150)square feet or less and single stury
shall he six t6t feet in all districts. hut in no case shall said accessol7•braidings he built closer than twelve t1) feet to ans
other building on an adjacent parcel. All sheds are required to he located!ham' (PH feetfrr)m any front lot line
Replace existing* Size L x iF x H
'The debris will he disposed of at: _
Location of Facility
I declare under penalties of perjure the statements herein contained are true and correct to the best of my knowledge and belief I understand that any false answerls)
will be just cause for denial or •ation o'my I• for prosecution under M.G.L.Ch.268.Section 1.
i✓ Applicant's Signatu . _ _ Date: �O -J"�C
\/
✓✓✓✓j Owners Signature for attachment) it Date: 0 '(pi-- " 5
Approved By: -_ — Date
Building Official(Or designee)
Zoning District: _
Historical District: Yes No
**Conservation review will be required if shed is placed within 10Oft of
wetland.200ti from riverfront.or located within a flood zone**
6.24
The Commonwealth of Massachusetts
.� Department of Industrial Accidents
Office of Investigations
I _ 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 �A \ /A/ _I' Please Print Legibly
Name(Business/Organization/Individual): ,•`Ie -cj I t7 Nile(
Address:On Fr a nee S !I eke n R c1
City/State/Zip:YarrelCt/l 'f' 14 A ODec 7 s Phone#: )79- y-3.30?51
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. 0 1 am a general contractor and I
employees(full and/or part-time).* have hired the sub contractors 6. 0 New construction
2.❑I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling
ship and have no employees These sub-contractors have 8. 0 Demolition
working for me in any capacity. employees and have workers' 9 0 Building addition
[No workers'comp.insurance comp.insurance.:
�r,-� ired.] 5.0 We are a corporation and its 10.0 Electrical repairs or additions
3.V'am a homeowner doing all work officers have exercised their 1 L❑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.E Other S)1�c�
comp.insurance required.]
*Any applicant that checks box#1 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 sub-contractors and state whether or not those entities have
employees. If the sub-contractor,hate 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 certif unde,the r r ins and penalties of perjury that the information provided above is true and correct.
Signatu - Allgoree Date: 0 9-a49s
Phone#: 174'9 tp 9 -33r)Y
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 20 Building Department 3fCity/Town Clerk 4.0 Electrical Inspector 511'lumhing
Inspector 6.0Other
Contact Person: Phone#:
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 #
rndicate lccatias of garage or
AdditIcno w dashed lima
accessory building
Sewerage �a dizp1 (cesspool)
W of
1 1
I
Abutter's I
Name I Abutter's
Lot Name
Lot#
If this is a 'LJ REAR YARD If this is a
corner lot,
write in corner lot,
name of street. R• write in
I' name of street.
I '7:C) n . <3.
3.
4 I
tq
SIDE YARD •
HOUSEsumYARD
•
:
•
•
•
•
•
SET BACK
•
•
•
3D
(at. ft. )
(NAME OF STREET)
—.—.). (-..f
/ N Info mat lcn
/ `. Supplied by