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Y'¢ office Use Only
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Permit epires I80 day.from
issue date
UILDING DEPARTMENT
EXPIZI_ . -PF'RMIT APPLICATION
TOWN OF YARMOUTH
Narmouth Building Department
1146 Route 28
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS: ` 4- 4-6, f INIcwititctid- vo,of
Kaw ioiNs (<<S
o Nl R _ 366 2 1 h(o R,0,60-61 Le, , 5eA 3c..-7-11 8?
'\\II PRI SI \T ADDRESS k TEL. a
CONTRACTOR: o(h -
NA'MnE. �� �,� \I\II IND ADDRESS TEL.tt
EMAIL: itIrVY\i#C.-€ 1f's!v°l(1tFCOM '
esidcntial X _Commercial Est.Cost of Construction S l(000
!Ionic Intprom cment Contractor Lic.# Construction Supervisor Lic.#
�( L. v H gSHED INFORMATION
Nos ! ' size i , _ �� 1 C _ v Corner Lot: Yes NoX
Per Town of Yarmouth liming By-Law Set. 203.5 ;\uic' E:
tinily u►hl rt'or I tlrtl Se'l/UJ k't If Or tit t t'1v0'1 biiildiiit,'F t 4Oiltliliiii.' Hilt' ilinitft'tlllIli t l 5lll square It't'I tlr lt'%S lilt! Slllt,'Ie .lrti't
,11t111 ht vit r151 lt't'/ 1H all tl1sil'k!t Intl ill in' t t1st' vMill Atilt!t1t't'c'ssuit' /Nilthll,t( ht. Mall 'I 'scr than in cISC 1l i1 lct'l I++ ill}t
Hllh'I' h illtlllt,t,'WI tall in h tltV111p 11 t et'l. .ill Alittly tilt' required tohe IHW'tlrt'tl//B 131 J'cllrnui ant In Mt lot!lilt'
Replace existing*_ _ Size L (2 r li. to x H g
*The debris will be dtspttlsed of at: .O M.IL rt u Sz.d- ( W1a l Vt 1 VI c,4 3 1;c0
Location of Facility
I declare under penalties of penury that the statements herein contained are true and correct to the hest of my knowledge and belief. I understand that any false answer(s)
will be just cause for denial or revocation of my license and for prosecution under M.(i.L.Ch.268.Section I
Applicant's Signature: __ - Date. -
Owners Signature(or attachment) Date:
\ppro\ed B. Date
Building Official tor designee)
Zoning District:
Historical District: Yes No
**Conservation review will be required if shed is placed within I(x)ft of
wetland.2000 from rivertront.or located within a flood zone**
6 24
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e..►V
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SHEDS LESS THAN 150 SO FT SHALL
RC-PLACED A MINIMUM OF 30 FEET
FROM THE FRONT LOT LINE AND A
PLOT PLAN t •'I'?l IMMUM OF 6 FEET FROM SIDES ANC
REAR LOT LINES
FOR LOT
Additicca w dashed�ljn ge _ accessory build j
Sewerage diapoeal (cesspool)
Well of
I (lot....gU........ft. ) I
I
Abutter's )
Name �y7 Abutter's
Lot I ® ,f)elvl Name
If this is a ,S► 'EAR YARD Lot p
corner lot,
I write in Si
If this is a
name of street. �- !0�� co
•••ft. mer lot,
write in
g_ I ®SdPfiir name of street.
r� V.` v +AnK 'a
8
4 i
c4
SIDE
V'— 2-0
' NOOSE �8 YARD •
lib•
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•
•
•
•
•
•
SET MACE
35'
- i..ft.
I
a
(lot SC ft. frontage)
\ /
(NAME OF STREET)
/ \ Informed=
/ •
supplied by SO IAh �7at�24k
The Commonwealth of Massachusetts
=• Department of Industrial Accidents
Office of Investigations
_=m1= Lafayette City Center
_ F� 2 Avenue de Lafayette, MA 02111-1750
•lBoston,
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization-Individual): —Mt/vv. -_ c .ztk
Address: 't-kU Ni-- ` A- NICVAA JOF
City/State/Zip: Phone#:
Are you an employer? Check the appropriate box: Type of project (required):
4 I am a general contractor and I
1.0 I am a employer with . C 6. ❑ New construction
employees (full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. El Remodeling
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 11.0 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 Ski i !3
employees. [No workers' 13 Other �l —
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
$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
fine up to p
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 ut er the pains and penaltie.' of perjury tha
t the information provided above is true and correct.
Stature: Date: lI1lI —
Phone#: 5 d D -�G-1- (1 7
Official use only. Do not write in this area,to be completed by cite or town official.
City or Town: Permit/License #
Issuing Authority(check one):
10Board of Health 20 Building Department 31:City/Town Clerk 4.0 Electrical Inspector 5F'lumbing
Inspector 61:Other
Contact Person: Phone #:
it
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