HomeMy WebLinkAboutBSHD-25-82- Office f Ise Only
RECEIVED
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SEP 15 2025 I
Permit expires 180 days from
issue date
BUILDING DEPARTMENT
By _
EXPRESS SHED P IT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth,MA 02664
b (i508)398-2231 Ext. 1261
CONSTRUCTION ADDRESS: 2 9 Rios U(/2 j
,E >��,�R/ s2 9711:- -o2 y.,3
\ODRESS ��/ TEL.
CONTRACTOR: Pair �}Y s3Qf� JN��ONT'C Rd
N\ME V\ILING A DRESS•
EMAIL: /f&N•YBNN�✓i4 it.
�. yr�,t/Nis MA
C vont 067: AJL� '!
�dential Cununrrctal Est.Cost of Construction) �OQQ eO-2
lion,.Improsemcnt Contractor Lic.fi Construction Supervisor Lic.0
/ SHED INFORMATION
Ness ✓ .Size L /�R' /5 x H Corner Lot:lies No
Per Bonn of Yarmouth Zoning;Bp-Lair Sec 203.5;Nine E:
Ciarunlrr.0 IwJscrb,ilk,{,r.lr<<swrrhnilaittc, .,n,.Initers/i/nrl?DIs,/tt,nY Singh'Srail.
shall hr(Il 6 1,.l itt;all digit,i, hill tit n. IOC,1f f/I s,na to sr,,,tri hudanre,hr huih(I /e 1/f in ntrlcr 11 I heel h, //it
ntln r huilaitie ant.tit u+l,: -ill/ducal lll uhr�h tiff rejuue I II,he',Wit/Ca/horn t 1h/,el fivnt,till h,wf lrrl hilt'
Replace existing* ✓ Size L x ii' /O x H /b t
'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 m)knowledge and belief I understand that an,false answer/sl
will be just cause for denial or reset-mien of m license d f prosecution under M.G.L.Ch.268.Section I.
Npplicanr,Signature �y/��j//r put. �nn—
Owners Signature for attachment) ^/ Date: 7 �s3
.Nppros ed Iis Date
Budding Official tor designee I
Zoning District:
HistoricalDistrice Yes No
.'Conservation res iew will be required if shed is placed within 1 OOft of
wetland.20011 from riserfront.or located within a flood zone••
6 24
"il. N
f* s1
SHEDS LESS THAN 150 SO FT SHALL
RE PLACED A MINIMUM OF 30 FEET
FROM THE FRONT LOT LINE AND A
;!. MINIMUM OF 6 FEET FROM SIDES ANC PLOT PLAN REAR LOT LINES.
FOR LOT II •
fidicabe locates of garage or accessory building
Additions with dashed lfnea
Sewerage disposal (cesspool) 65
weal co
I I
- - -- I (lot ft. rear)
Abutter's i
Name ( Abutter's
Lot# ( ice, Name
If this is a Lot#
corner lot, REAR YARD
If this is l a
t
write in �_ corner lot,
name of street. 1 write in
name of street.
3.
v
la
gi
SIDE YARD
•
,y__ NOOSE SIDE YARD •
•
•
•
•
SET SACK
Pt
4
1
,d
(lot ft. frontage)
‘ // �l� '�L/�Sl
\ (NAME OF STREET)
...._.4 F-
/ \ Informat::ian
/ \ Supplied by ^� 1 L�/1J61 V( L
:=- The Commonwealth of Massachusetts
teasi
' Department of Industrial Accidents
1=.......30k
Office of Investigations
El Piii__ 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): OA) PIfJ Le(1 / <--L-
Address: 3? 6AA),ga,2/' v i (SD. yfikrk 0 u-r-f,t IM► - 1)=2d41
City/State/Zip: So tt iel //¢�D'lt2L,{ Phone#:_97,g'-- 8a (--m2 t(.
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 g. ❑ 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.❑ I am a homeowner doing all work officers have exercised their 1 1.❑ 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' 13.0 Other
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
fme 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 pai an penalties perjury that the information provided above is true and correct.
Signature: 1 Date: 7— s---- 4
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 3❑('itv/Town Clerk 4.0 Electrical Inspector 5F'lumbing
Inspector 6.0Other
Contact Person: Phone#: