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`� o� k�, RECEIVED Office Use Only
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BUILDING DEPARTMENT Permit espires 180 days from
BY- ------ owe 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: /_ /577 ,9v/4(� �� �G �E e/Y/1C/
t)u.NI R. !'. � fl� -° ey `Ji9✓11� 7-7 a,'; -g 974
NAME PRI-SI\T ADin<I s, TEL =
CONTRACTOR.
(
vA�fh __. �1 sI uLfnc ADDRESS rii=
V
EMAIL: I,:e0": 45 A43� , >1 N .ed'
11;:sidential _Commercial Est.Cost of Consruction /0-I'10.de
Home Improvement Contractor Lic.# Construction Supervisor Lic.#
SHED INFORMATION
Ness 40444ze L s W to H Corner Lot:Yes No Ili
Per Town o/Yarmouth h 7.uniwl Br-Lao'See 203.5 Note L:
Yid.',no-/rrru,I,turf t,th,t.As tnr,rrtrsturt building,,ntt,mila'rah!htmrli,.11i/n r l?ii.,/mur tee,„r less,ru./sele/,st„n
shell h,'sit,h,/rrt ti,dl dorm is.hot ur tit,,,nr,hall raid.n .term hml./in.et A. haih cl„,er turn,it. Ir r,I_',trA is„tin
„NI,r 1,ulh11,1g nit,tit tidbit 011 pill,.i 414ll,,lr-,in,u-r rryenr rd rn hr 10,111,1111110 r i11,lrel iri,111 grit/rout lu1 lnr,
Replace existing* Y Size L_ KII /O r N
"The dehns will he disposed of at:
Location of Facility
I declare under penalties of perjury that the statements herein contained arc true and correct to the hest of my knoo ledge and belief.I understand that any false answerlsl
will he just cause for denial or re.°cation of my license and Ibr prosecution under hl ti L.l'h 268.Section I.
Applicant's Signature- _ fate. hr .C��1�
Owners Signature for anaehme nr— _4.G ire/,/t __. _ Date: �////1)OY
hpproted Bt. Date
Building Official for dcstgneet
r Zoning District: 1
Historical District, Yes No
”Conservation resiew will be required if shed is placed within I0011 of
wetland.NOR from riserfront.or located within a flood mite••
6 24
SHEDS LESS THAN 150 SQ FT SHALL
RE PLACED A MINIMUM OF 30 FEET
FROM THE FRONT LOT I INE AND A
MINIMUM OF 8 FEET FROM SIDES AND
PLOT PLAN REAR LOT LINES.
FOR LOT I
IhdiCaite location cif garage or accessory building
Addition with dashed lines
Sewerage dizpoeai (cesspool)
Well to
I
I
Abutter's 1 (P
Name I Abutter's
Lot# Name
CP 1 Lot#
If this is a - REAR YARD
corner lot, If this is a
write in corner lot,
ft
name of street. I write in
name of street.
8
�o
4 I +t:
SIDE YARD
HOUSEalDE YARD •
•
I
SST BACK
•
:
ft.
301 .o.
(lot ft. fzzntage) .
\ // I &fl 3-€G U I et.t) _A-
/ (NAME OF STREET)
" >
/ Information
Supplied by
P` The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Lafayette City Center
G'�-�f 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): 42 /
Address: /)7
oa6e
City/State/Zip: 494 phone#: v
Are you an employer? heck the appropriate box: Type of project(required):
I.❑ I am a employer with 4. ❑ I am a general contractor and 1
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. El Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
workingfor me in anycapacity. employees and have workers'
9. ❑ Building addition
[No workers' comp. insurance comp. insurance.:
� r�e fired. 5 El We are a corporation and its 10.0 Electrical repairs or additions
3.LUG 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.❑ Roof repairs
insurance required.] t c. 152,§1(4),and we have no
employees. [No workers' 13.1=1 Other
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
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. lithe 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.
./Signaturg✓i j �X 4- Date:
Phone#:
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License #
Issuing .• uthorit (check one):
1013oard of Health 20 Building Department 31:City/Town Clerk 4.0 Electrical Inspector 5EI'lumbing
Inspector 6.DOther
Contact Person: Phone#: