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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: 73 Brookhill Lane, West Yarmouth, Mass. 02673
OWNER: Harold S Ellis Trust 73 Brookhill Lane West Yarmouth, Mass. 02673. 407-808-3388
NAME PRESENT ADDRESS TEL. #
CONTRACTOR: The Shed Place. 620 Rt. 28, Mashpee, Mass. 508-477-6888
NAME MAILING ADDRESS TEL.#
EMAIL: hellis3388@gmail.com
®Residential 0Commercial ❑Est.Cost of Construction$$9,000
Home Improvement Contractor Lic.# Construction Supervisor Lie.#
SHED INFORMATION
NewX Size L 14 w 1 0 x H 6 Corner Lot:Yes No X
Per Town of Yarmouth Zonis#,'Br-Law See 203.5 Note E:
Side and rear yard,setbacks fOr accessory buildings containing one Itiwdredlifty (150) square feet or less and single story
shall he si.a: (6) feet in all districts. but in no case shall sail/5k ces.sory buildings he built closer than twelve (12)fi�et to ant
other building on an adjacent parcel. All sheds are required to be located thirty (30)feet front any front lot line
Replace elating* 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 re oc o f mylilicense
and for prosecution under M.G.L.Ch.268,Section I.Applicant's Signature: �. ( (/�L(./- Date: 9�ehq 3o, 20 /
Owners Signature(or attachment) 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
xi = Office of Investigations
Lafayette City Center
ti72)
- 2Avenue de Lafayette, Boston,MA 02111-1750
=M r- www mass gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): U A�.Q LO S. ELL i C
Address: 73 BEooi-Idl t-( £_lank.
City/State/Zip: }} ..''� £Z(073 4 ' 7- .336
ty p: We Sr YAkfroav--N, nA. Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. 0 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. 0 Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
workin for me in anycapacity. employees and have workers'
g P n' 9. ❑Building addition
[No workers' comp.insurance comp.insurance.: 0. Electrical repairs or additions
required.] 5. ❑ We are a corporation and its 1 ❑ P
3.X I am a homeowner doing all work officers have exercised their 11.111 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
employees. [No workers' 13.0 Other
comp.insurance required.]
*Any applicant that checks box#I 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.
1 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 ce the pains and penalties of perjury that the information provided above is true and correct
Signature: COS-eG1_ Date: / 1f�4C,1/ 30. 20Z6 .
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 21:1 Building Department 313City/Town Clerk 41:1 Electrical Inspector 51:1Plumbing
Inspector 6.DOther
Contact Person: Phone#:
\ Zone R-25
Mop 23 1 25,000 Sq. Ft.
��AjParceI 100 130 69, \ 150' Frontage
'\ Setbacks
— f \ `' ' — \ Front 30'
23 E, Q \ (� Side 15'
113 3°5 50 , c -- J 'a, o/w .�- , a Rear 20'
N \ -o C�
\ .•— "' 1) �" 1 Maximum Coverage
� '' i j�J \
I / cs. i� — ;, -' - \\ \ U.. Existing Coverage:
43.5' ` 16�; r' ' q0 \ �� Proposed Coverage:
�� Garage 1� 06' \ .1
al .Afari,410.00eeel �-,-'' C.' `\ 1 219 :I. c)F.. \ 1.) 1
fu Addition _-.\\ 1 \\ ., \ i `` \ 2,
-� �� — \\ ` House # I.5 \ 6) \� 3. I
�eW \` 3 Bedroom ` 4.
Zr
, Existing Deck \ s• F
:-- /Ox /�i: ' to be removed o"'\� \ ` -� \
\ 5.)
° S 1 E -- - ,---`14 \
44 4 ‘ .-: --.:7-1\ \-\\ o o.,c..
k.t \-, ST \Patio` 90
\\ I `\
— \\--,--- 0. Plot Plc
O — 1 _ -- ' 0\0 For
o $h�— f J ?-
Co ?•"\6'00 Proposed A
\� r ' J S 73 Brookhill Lane
Map 23 Prepared for:
All
Parcel 117
Harold Ellis
9�0' 652 Lake Cove Pointe CirWes
\ JO E G y$Ek Winter Garden, FL
()r`N 007Ehei co aart,it1444, ,.,t,of�dgssDate: June$eQ6 Iv(ap 2��PSTEPHEN�c Revised Date: Au
S 2 Parcel 116 B.e: --1/; GRAPHIC
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