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Home My WebLink AboutBSHD-25-72 application :fig Ih RECEIVED Office Use Only 41 0 Q 2025 3 v • Permit# H �, AI IG �J' Amount 5 ''�C�RPORA 5 �69� cas BUILD! TMENT Permit expires 180 days from By issue date EXPRESS SHED PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 WE ST E—S M (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: CIO L •_ \ RD, I�/ ' V 11kP6 RT • OWNER: COtAtelt 12 E:A -z1( ) �Mc i•vu t Gbg-364—tip 77 NAME 9�r( PRESENT ADDRESS TEL. # CONTRACTOR: d � wow e Rix 5b5zi3C • Z800 L/ /l, NAME�/ MAULING ADDRESS TEL.# eO l/ EMAIL: 11?`tom CA-, am .t/w S7 �?cr Residential ❑CommeercialQ t/ Li Est.Cost of Construction$ g160 • 3 Home Improvement Contractor Lic.#/t3 t 5 Construction Supervisor Lic.#(S J-"07QLO5 ✓ SHED INFORMATION New V Size L t4' x W 10 x H Corner Lot: Yes No ✓ Per Town of Yarmouth Zoninw By-Law Sec 203.5 Note E: Side and rear yard setbacks for accessory buildings containing one hundred fifty(150)square feet or less and single story, shall be six (6)feet in all districts, but in no case shall said accessory buildings be built closer than twelve (12)feet to any other building on an adjacent parcel.All sheds are required to be located thirty(30)feet from any front lot line Replace existing* ✓ Size L x W 12- x H J� /� *The debris will be disposed of at: t- A r ... 'Gn An d : 1 L�l 1"�,1'� o42,4 S Location of Facility 1 I declare under penalties of perjury that the statements herein contained are a.- .r s •ect to the best of my knowledge and belief. I understand that any false answer(s) will be just cause for denial or revocation j� 1Ltlioff�my license and for 7prosecuti. • • e Ch.268,Section 1. ✓Applicant's Signature: e 'YJI ' 4,44 or".- I Date: \8`ac-.) ✓ Owners Signature(or attachment) Date: Approved By: Date: Building Official(or designee) Zoning District: Historical District: { Yes U No **Conservation review will be required if shed is placed within 100ft of wetland,200ft from riverfront,or located within a flood zone** 6/24 Lite Commonwealth of Massachusetts Department of Industrial Accidents = �s Office of Investigations Is = �1„ =_ ;1 Lafayette City Center -ear 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): Address: City/State/Zip: Phone#: 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.El 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' p $ 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.❑ Roof repairs insurance required.] t c. 152, §1(4),and we have no 13.❑Other employees. [No workers' 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. 1 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# . Issuing Authority(check one): 1❑Board of Health 2❑Building Department 31:City/Town Clerk 4.0 Electrical Inspector 51=1Plumbing Inspector 6.0Other Contact Person: Phone#: The Cotntnonweanh of Massachusetts 1_mtr�,.i Department of Industrial Accidents +__ 1 Congress Street,Sane 100 • _f_� Boston,MA 02114-2017 • Workers'Compensation Insurance Affidavit:Bntl'der ontradon/Elecericians/Plmnbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Molicant Informs tiop e Print 4ealbiv Name(Business/Organuallod[ndividuai):�'i VA,ilarbsr Wart `Y.-re,c).� ,s t,L C Address: 2.S 4 alkiRM City/State/Zip74 qsr\r41&N1I'e csZgAs phone*.go% - y'3 0 -Z$e90 Are�T''za colder r'Cheek the appropriate ben t rf t a Type of project(required): tE tlltii �9. employees(full ender parbtune).• 2.0 I am a sole proprietor re partnership and have no employee, 8.o Re o construction any eapecay.(No workers'comp.insurance required.] wortutg for metier, . 8.❑Remodeling 301 am a homeowner doing all wok myself(No oaken'comp.instance required.)r 9.,❑Demolition 4.01 am a homeowner and will be hiring comraclo,to conduct all wok m my property.I will 10 Q Building addition ensure the all eootramora either hive takers'mmpe ution MUMMY or are sole 11. Electrical proprietors with no employees. ❑ rerepairsrs or additionsddttios 12.❑Plumbing repairs or 5.0 I B nor and I have hired the subcona 'co listed eta the attached sheet employees and have vxkrten'tamp.insurance.: 13.QRoof repairs 6.0We ereaoorPmatiort andinoSiiarslave exercised their right ofexwmptoa Per MGt e. (4.QOtber 152•11(4),sad we have no employee.(No wakes'comp.jyurarkce raquimd) 'Any apt tam that checks box#1 must mho fill ma the section below showing their workers'compewtua policy information o Homeowners who submit this affidavit indicating s ing they are doing a work and then him outside contractors must submit a new agle ash indicting Each tCmmaesors Mat check this box must attached ea additional sheet showing the name of the sub.contracmn and nate whetter cc act those entities bare employees.If the sub-contactors have employees,they must provide then starkers'comp.Policy mots. am an einployer that is providing workers'compensation irsaarnnce jor my employees Below is theand job site information. ( m j (� policy 1 Insurance Company Name: aQt(�$hikf tg1Y1"�P�a —i—^f�Gu L 1�pRin.S.(t1 Policy d or Self ins.Lie.N: — I2 4 9?02 Expiration Date:2 J'Z I.26" lob Site Address: Ciry/3telelZip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c.152,§25A is a criminal violation punishable by a fine t$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.A copy of this state ern forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify the ofperjwy that the ihiellm tion provided above B true wed comet Signature: Date: 7'/i/0/F- - Phone#: C Q -8 — Y3 0—7 v) ,OB'icial use only.Do not write in this area,to be completed by city or town official .. - wier City or Town: Permit/License k Issuing Authority(circle one): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: PLOT PLAN FOR LOT # lbdicate Additions with hed of garage or accessorY building Sewerage disposal (cesspool) 69 � 01 I I --. -- --- 1 (kit ft. rear) ' c: j Abutter's C(L 1•Ati D Abutter's Name Name Lot# Lot# If this is a REAR YARD If this is a corner lot, corner lot, write in ft. write in name of street. j name of street. I ti 11 SIDE YARD HOUSE SIDE:ARD I SET BACK • I (lot ft. frontage) , 9)62- W r 1 M a U'rN Rp , / / (NAME OF STREET) In]Ixu.uiat ia' `• Supplied by Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Lafayette City Center, 2 Avenue de Lafayette Boston, MA 02111-1750 Tel. (617) 727-4900 or 1-877-MASSAFE Fax (617) 727-7749 Revised 7-2019 www.mass.gov/dia - :e. o JO $ f� i iAtizAsaeviemal- . Office of Consumer Affairs and Supinessiteguietian .., 10 Part Nader-Suite 5170 Boston, ••. etts 02116 . • 1 HomeImltrovement'• ; - Registration: _ -. Commonwealth of Massachusetts • j...i i _ 10 Division of Occupational Licensure �}POST'&BEAM CO. 4i17 Tizs Board of Building Regulations and Standards le 2 59 IiEN ANNE RD. McGRATHr `- Constructi �;�(IperJl1 8 2 Family11, HARWICH. 'y "_ r t -. - y CSFA-073865 � @�Ipiros:03/14!l02B MA 02645. •-I - •7 JAMES R MC RATH 204 CRANVIPW RD 'Y BREWSTER l A 02031 • i R+Ot v��y. ' .. t 1 e a h '1Ul.f.V.1:lJl Commissioner .>`1,40,,..._- THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs and Business Regulation 1000 Washington$trleSt-Suite 710 Boston Massachusetts-.02118 Home improvement registration I"i,---- • Type: CO/PWWWn MCGRATH POST A BEAM CORPORATION '.a,_ ^' Fte 13/935 D/B/A PINE HARBOR WOOD PROD. . + ^f'�--,.., ion: 10lA0/2026 259 QUEEN ANNE RD. ram.: HARWICH,MA 02645 v sa▪W-J1' 410RIC' .. .__ Upe .Addrw.end R.lU Cern. THE COMMONWEALTH OF MASSACHUSETTS OHI0.of Con.unwr,Ana.A Bush..Rap uleeon Rspl.fn.on wild for IndlYki.l us.only Delon mu HOME IMPROVEMENT CONTRACTOR .dpk.0on ds1..R found RN.ea: TYPE:CO3Cora,On O1110.01 Con..A s.Ragul.Non asaliSallles FiaYlman 1000 Weaning, M•SPIN 710 132935-- 10002020 B,.1on,MA 1A e MCGRATH POST A BEAM CORPORATION GAYA PINE HARBOR W000PRDO. JAMES R.MCGRATH .`. �,y� 259 QUEEN ANNE AD- f tt,d.. HARWICH MA 02645 Undersecretary N id withoutsigns /