HomeMy WebLinkAboutBSHD-25-98 •
+t�. Office li:•Onlyo1. : RECEIVED , TD-•
�S
NOV 04 2025 •
Amount
Permit expires 180 days from
BUILDING DEf'ARTMeNT { issue date
By
EXPRESS SHED PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth,MA 02664
I `� (508)398-2231 Ext. 1261
CONSTRUCTION ADDRESS: Tk A N Q4
Mike t1ca(
Lift_
OWNER: -1Ok v FCt±-7C4C ([o( rel a ecrry Litt _.. SA-10-1,2-21
NAME PRESI NT ADDRINS TEL.
CONTRACTOR: SGimQ-
NAME /� Al\II.ING ADDRESS TEL.
��`EM//AIL: +erht+e.CC-I:.-,MAI�,Cvw
t( sidcntial _Commercial ESt.Cost of Construction S�,
Home Improvement Contractor Lic.# Construction Supervisor Lie.#
�/ SHED INFORMATION
New /1l Size L 12 x N' g x H Corner Lot:Yes No X
Per Town of Iilnnoul6 Zoning 8p-Lan'Sec 203.5:Note E:
Airlr�onl rr�ri 1,161 ,vhn,k,Gn,u tes,itel 'slit' r 1511,syls t l tir ls'„,u/I iin'I, %hel.
,lr�rl1 hr,it h,I,,!In ail/,I,,nv,r, bill in nit„1,, ,1r,dl,,lid/ is,r,sort /'uil,bilt,hr hoi/I,I n,llr,ui Is, /-'i tee/In.un
(WWI'hail/ink in till tit i,n etil linrrrl -Ill-,hed,one rrquirrdlo he lni,pe,/111,rn iilli fs's'IJnini.nn Jrniu In!!Inc
Replace existing*71'5 Size L x S.II x/l q �`
•The debris will he disposed of at SOVVLQ,. {Q.(A' _o revv'C.(i.tpi- �=
Location of Facility J
I declare under penalties of perjury that the statements herein contained arc true and correct to the best of my knowledge and belief I understand that any false answertsl
will he/nit cause for denial ora ree_socittion of my license andn Illy prosecution under M i i.L.Ch.268.Section I. I I
Applicant's Signature %1y'V rr` •GY __ Date `01 2; 1�75.
(� 1012.1`202S
Owner Signature(or attachment) • r{✓"•c c(�4 Date:
U
\pponcd Its Dates
Building Oflictal(or designee(
Zoning District:
Historical District: Yes No
..Conservation review will be required if shed is placed within 100ft of
wetland.200fi from riserfront.or located within a flood nine••
b 24
t1.
SHEDS LESS THAN 150 Scab FT yHALi
RE PLACED A MINIMUM OF 30 FEET
FROM THE FRONT LOT LINE AND A
Attil\'IMUM".61T 6 FEET FROM SIDES ANL`
PLOT PLAN kEAR LOT LINES.
FOR LOT •
•
I77diczt]e location df garage ar Act gory building
Addit>afua with dashed lines
Sewerage d 1 (cesspool) E
Well cgs
I I
I (]at SO
ft. rr) 1
Abutter's
4 III
--
Name I (•eadeN + i '/ Abutter's
Lot# I _Et-Field 1 ,`f $X� Name
I Shed Lot#
If this is a ! REAR YARD
corner lot, r If this is a
write in i I dl R. comer lot,
name of street. Q — 12►_p write in
(� Q}�L name of street.
+anK •`15' s
ti
cq
: SIDE
h 7 HOME
YARD
Ike a ;
W
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: Q
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SET RAM(
ft.
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not gp ,
. ft. frontage)
N.
// l•Icc o...ka�t,,c IAA—
(NAME OF STREET)
- "—
/ Fn> maticr
/ \• pplied by
a' �\ The Commonwealth of Massachusetts
.—. -- Department of Industrial Accidents
e;LV --r 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 Legiblh
Name (Business/Organization/Individual): - ---01/1 V\ �Gt-f-c-z&tk
Address: 'fa '4" [ A- Gu%-L e-
City/State/Zip: SO I V U 1t1 \ Phone #: 5 0S - C' 11 281
Are you an employer? Ch k 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. II 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 R. i Demolition
working for me in any capacity. employees and have workers' 9 n Building addition
[No workers' comp. insurance comp. insurance.
required.] 5. El 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.n 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 S t' t
employees. [No workers'
comp. insurance required.]
*My 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
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.
1 do hereby certify under the pains and penalties' of perjury that the information provided above is true and correct.
SignatureCyA ���: -3t/�L Date: 12-11 44s
Phone#: 5o .- 30- 12-81
Official use only. 1)o 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 212 Building Department 3fl('itr/Town Clerk 4.0 Electrical Inspector 5fl'lumbing
Inspector 6.0Other
Contact Person: Phone #: