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HomeMy WebLinkAboutBSHD-26-6 application r_ 01' ` office Use Only 3 h � Pen„it: S/-0:/6 k.t_-_ vior.�,,:'14. • Amount 3 .. Oq POV•i En __ ' Permit expires 180 day.from :. • issue date EXPRESS SHED PERMIT APPLICATION -5.cd TOWN OF YARMOUTH Yarmouth Building Department 1 146 Route 28 South Yarmouth, MA 02664 (508) 398-2231 Ext. 1261 CONSTRICTION ADDRESS: I N ©iici Icic,. . OWNER. Nu\:1vG ‘ M`G,-ta ► V.V111_ Lar2 50B 341 o1(G.8 \\\IF PRI SI\T.ADDRESS TEL. = CONTRACTOR: NAME. \,I\ICING ADDRESS TEL. EMAIL: /Residential _Commercial Est.Cost of Construction S Home Improvement Contractor Lic.# _ Construction Supervisor Lic.# SHED INFORMATION l 1 New Sire L 1 t, x W to NH kO t 4 it Corner Lot: 1'es No Per Town o/ Yarmouth ZoninL' Br-Lars'Sec 11/3.5 Note E: chit't/Ili/rear tort/1ei/'th As for tkt'ssol't /till/tl/I/!s t ttllltllll/ll! imc /itimIr 1/lif/t i/Sill sgtio c lttl ,N. less ,llh/ single shh't. v)kill l't' Qv ihi AY/ ii, ti//t/is//'!t is hill in no ise' slit/// Stlhl tit t t'..rli-i billltllll,L'. /et' biii/i t h11er i/h/!/ /ttt•ll.t t l_'t led /n alit oiht'h hli/hi/li,k OH tul tltlltit till/lt/i'Cel .All.%httt1 arc required it) he located ihir/t rillijectJi-ion slit /10//i hit llur 12/ 9, �, y,, Replace existing* Sire L 12 x it" g" x H 8 2 ShA8S *The debris will he disposed of at __ da)* .-t l(,v1.t- L Location of Facility I declare under penalties of pertun that the statements herein contained are true and correct to the hest of in., know ledge and belief. I understand that an false anssseris) will he just cause for denial or relocation(Amy lice . at I to rosccution under M.G L.Ch.2('S.Section I Applicant'sStgnatureQ \ Date -b & 2,0Z(0 Owners Signature for attachment)4 Date: \pproscd By: Date I;wldim_official f or designee) Zoning District: Historical District: Yes No **Conservation review will be required if shed is placed within 100ft of wetland.200t1 from riserfront.or located within a flood tone*' b 24 N The Commonwealth of Massachusetts Department of Industrial Accidents + Office of Investigations I .= Lafayette City Center 2 Avenue de Lafayette, Boston,MA 02111-1750 -4/ www mas&gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): 'Vo.k.,\vtit. AQ.G<A k Address: ( -b l L a - City/State/Zip: 5w lo.c rvwL' ' J 0 2"LI Phone #: 5067 3`-t( O((, Are you an employer? Check 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. ❑ New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ElRemodeling ship and have no employees These sub-contractors have 8. 0 Demolition working for me in any capacity. employees and have workers' 9. 0 Building addition [No workers' comp. insurance comp. insurance. r�utred.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.WI am a homeowner doing all work officers have exercised their 11.❑ 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 13.❑ Other employees. [No workers' 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 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 certify under the pains and penalties of perjury that the information provided above is true and correct. / 'u Signature: Date: (0 202 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.❑Electrical Inspector 5Elumbing Inspector 6.0Other Contact Person: Phone#: SHEDS LESS THAN 150 SQ FT SHA'_L. _� RE PLACED A M(N!MUM OF 30 FEET FROM THE FRONT LOT LINE AND A • • MINIMUM OF 6 FEET FROM SIDES AND PLOT PLAN kEAR LOT LINES FOR LOT # hellcats locatics of garage or accessory building Additions with dashed lines ----------- Sewerage disposal (cesspool) 69 Well E I ' ( ft rear) Abutter's � Abutter's Name Name Lot R ( Lot R If this is a d— REAR YARD If this is a corner lot, 4)\-z& corner lot, write in ft. write in name of street. �, name of street. - a $ I SIDE YARD SIDE YARD HOME SET BACK ft • (lot ft. Ercntage) • • 1 L L Lone, (NAME OF STREET) / Informattra / Supplied by