HomeMy WebLinkAboutBSHD-25-101 -\ R F C, O Use Only
,1 • Ci 7 oVniit�
rN ~ 1 NOV 07 2025 Amountal5" 7 /
Alwo 4 Y Permit expires 180 days from
B U i L D I N C issue dateEXPRESS 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 Schemel 92 Partridge Valley Road, West Yarmouth, MA 02673 860-235-8184
NAM!: PRESENT ADDRESS TEL. #
CONTRACTOR:
—— - —---__-___---------
NAME MAILING ADDRESS TEL.#
EMAIL:amslupecki@hotmail.com
Et Residential 0 Commercial C Est.Cost of Construction$
Home Improvement Contractor Lic.# Construction Supervisor Lic.#
SHED INFORMATION
,i tt
New X Size L E 0 x W �D x H `-g Corner Lot:Yes No X
Per Town of Yarmouth ZoninL 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)feetfrom anvfront 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 false answer(s)
will be just cause for denial or revocation of my license and for prosecution wider M.G.L.Ch.268,Section 1.
Applicant's Signature: ()VA- Date: 11 l ✓ �-J
Owners Signature(or attachment) J\�_1 Date: Il ,j 1 ?`
Approved By: // ///�\ Date:
Building Official(or designee)
Zoning District:
Historical District: fl Yes fl 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
:=` °.. Ilse Commonwealth of Massachusetts
Department of Industrial Accidents
`'`-- , Office of Investigations
r t__
i=' Lafayette City Center
u " -' ' 2Avenue de Lafayette, Boston,MA 02111-1750
" -e- . _; www.mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leeibly
Name (Business/Organization/Individual): Anna Schemel
Address:92 Partridge Valley Road,
City/State/Zip:West Yarmouth, MA 02673 Phone#:8602358184
Are you an employer? Check the appropriate box: i
4. general contractor and I Type of project(required):
1.❑ I am a employer with I am a 6. IN 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. ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
workingfor me in anycapacity. employees and have workers'
p ty $ 9. ❑ Building addition
comp.[No workers'comp.insurance cop.insurance.t
required.] 5. We are a corporation and its 10.❑Electrical repairs or additions
q ] officers have exercised their 1 1. Plumbingrepairs or additions
3.® I am a homeowner doing all work ❑ P
myself. [No workers' comp. right of exemption per MGL 1 .❑ Roof repairs
insurance required.] t c. 152, §1(4),and we have no 13.0 Other
employees. [No workers'
cone.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
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 certtif j•under the pains and penalties of perjury that the information provide correct.d above is true and
Signature: ` /t/.A..._ Date: I(I 3 OS
Phone#: SQ 0 3 5
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):
lDBoard of Health 20 Building Department 3tCity/TownClerk 4.1:ElectricalInspector 50Plumbing
Inspector 6.0Other
Contact Person: Phone#: 1�