HomeMy WebLinkAboutBSDH-25-100 / ¢�Y ,At;\ '_ ..._ Office Use Only
Permi D— ,.l
, 7-s NOV 07 2025 l�5' '
Amount
`z J'e .n�Y 1
K, RPORATEe L D I Permit expires 180 days from
( B issue date
EXPRESS SHED PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth,MA 02664
(508) 398-2231 Ext. 1261
CONSTRUCTION ADDRESS: 92 Partridge Valley Road, West Yarmouth, MA 02673
OWNER: Anna Scheme) 92 Partridge Valley Road, West Yarmouth, MA 02673 860-235-8184
NAME PRESENT ADDRESS 11,[. 4
CONTRACTOR:
NAME MAILING ADDRESS TEL.#
EMAIL:amslupecki@hotmail.com
Q Residential ❑Commercial C Est.Cost of Construction$
Rome Improvement Contractor Lic.# Construction Supervisor Lie.#
SHED INFORMATION
l I 1 d i
New X Size L�72 x W v) x R D'2 1G Corner Lot:Yes No X
Per Town of Yarmouth Zoning 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 he 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 x H
*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 best of my knowledge and belief. I understand that any fake answer(s)
will be just cause for denial or revo-ation of li- e and for prosecution under M.G.L.Ch.268,Section 1.
Applicant's Signature: Date: (1( 3 I P5
Owners Signature(or attachment) (2/(A/YL.-- Date: 15 I
Approved By: Date:
Building Official(or designee)
Zoning District:
Historical District: fl Yes H 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
PLOT PLAN
FOR LOT
Indicate locati
Additions with�dashed of garage or building accessary
WSewell so disposal (cesspool) 9
.
I
I
Abutter's IAbutter's
Name I Name
Lot* ILot*
If this is a REAR YARD If this is a
corner lot, comer lot,
write in ft. write in
name of street. name of street.
•
SIDE YARD B YARD
G—__ H6t7SE ——
SET BAC'
I l
V
(lat ft. frontage)
,\ /, (ern �i ((fy
\ / (NAME OF STREET)
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, 14
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 r I
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwellinghouse 2 '�7
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 1.52,.§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 fndustrial
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
Revised 7-20 t 9 Fax (617) 727-7749
www.mass.gov/dia