HomeMy WebLinkAboutBSHD-25-105 O �,j\ ,
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0: Office Use Only
•
C:> Y Permit5i{4z,'a7�
Amount
`r..,„RPONATED�b lJ l �:.... NOV 20 2025.
�-_✓ Permit expires 180 days from
.
issue date
EXPRESS SHED PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261
b CONSTRUCTION ADDRESS: 0 eR 0 LAT_ C A
OWNER: 76 /1'1 Z e b s o .335 -a 63?
NAME PRESENT ADDRESS TEL. #
CONTRACTOR: 'S A IV/
NAME MAILING ADDRESS TEL.#
EMAIL: 'Gne,t.ID CcipeC oc peA.'ki . civil
'Residential c Commercial Est.Cost of Construction S
Home Improvement Contractor Lic.# � 1 4� 3 1 Construction Supervisor Lic.#
SHED INFORMATION
New Size L /0 x NV 9 x H ct 1— Corner Lot: Yes No
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 be 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 clispo,ed of at:
Location of Facility
I declare under penalties of perjury that the s tements 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 denia r revocation my ice, and for prosecution under M.G.L.Ch.268,Section I. A ,
Applicant's Signature: - • Date: V, 2 o f a 0 S S
Owners Signature(or a ment) Date:
Approved By: Date:
Building Official(or designee)
Zoning District:
Historical District: Yes 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
The Commonwealth of Massachusetts
Department of Industrial Accidents
`= Office of Investigations
:teaLafayette 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): Cy,. _
Address: N.p 0 q,(-, P( OS
City/State/Zip: (iA,Pmo;>11 P0* Phone#: 33 —
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a er w employer 4. ❑I am a general contractor and I
p y 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. ❑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.t
required.] 5.❑ We are a corporation and its 10.0 Electrical repairs or additions
] officers have exercised their 11. Plumbingrepairs or additions
3. I am a homeowner doing all work ❑ eP
myself.[No workers'comp. right of exemption per MGL 12.❑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.
tContractors 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.Lie.#: 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 ce ' under the e and penalties of perjury that the information provideded above is true and correct
Signature: { Date: / v e/c OJ ckiJ
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 31:City/Town Clerk 4.0 Electrical Inspector 5E'lumbing
Inspector 6.0Other
Contact Person: Phone#:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Stew 11=-
• =� = 1 Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.,aov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information PIease Print Legibly
Name (Business/Organization/Individual): h^ D
Address: •
•
City/State/Zip: a,!` ), 1r'Uv� Phone#: Cj �� Sri: 6 39
Are you an employer?Check the appropriate box:
Type of project(required):
I.❑1 am a employer with employees(full and/or part-time).* 7. ❑ New construction
2.0 1 am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling
anyny capacity.[No workers'comp,insurance required.]
' 3.a'I am a homeowner doing all work myself. r 9. Demolition❑
y [No workers'comp,insurance required.]
4.01 am a homeowner and will be hiring contractors to conduct all work on mYP property.e I will 10 Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
proprietors with no employees.
12. Plumbing repairs or additions
5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.Q Roof repairs
insurance.;
sub-contractors have employees and have workers'comp. insance.= n
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. I4. Other p t S h I�iC
152,§1(4),and we have no employees.[No workers'comp.insurance required.] '3- LI C AA S
'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.Lie.#: 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 MGL c. 152, §25A is a criminal violation punishable by 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$250.00 a
day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
1 d hereby cer ' under the ins a penalties of perjury that the information provided above is true and correct.
Signature: � �i . ��--
Date:
Phone#: S O$ ,�35 — ci3 C,
Official use only. Do not write in this area, to be completed by city or town official
City or Town: Permit/License#
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
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