HomeMy WebLinkAboutBSHD-26-21 of-Y`> -• RECEIVEDI
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' Permit' M/"1-0
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BUILDIN DEPARTMENT PermttcspiresISO days from
By —" — 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: _ 1.3 ID i.Ave, A V
OWNER. Rob e.--Tse,b �A0�& 13 DIti/u AuE To15-c33z-SS11
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N\\1i, PRI•SI\T ADI)i(i•SS TEL
CONTRACTOR Z' R Qgm5)-SS 7-9400
%A\IF M\ILING.\DI)RLSS TEL =
ENTAIL: IO b!rL,rl e.14_13 €g ry 1c t.1 i . CO(Yl
�/ S-93 9 t csc�
J_Residential _Commercial Est.Cost of Construction S
Home Intpres merit Contractor Lie.# Construction Supervisor Lic.#
SHED INFORMATION
I I /
New "IC. Site L 1 —x\\' 1'2.- x H ID ,3 !f Corner Lot: 1'es No
Per/i.n ii r[ )tit inolil/l/i ium! By-Law Sec 2113.5 .\rNe L:
S'I: :11�•i i',. '+" l:.��. 1 ..,..� ).-eP. .4..t'+ 1,Ir.'.`J! .rL.. •.Ii ,li /c;' :r: ,
...lull fl .t�: 14'41 fl,"II.f1tt.•-,1t kid 11+ i. ..1, '1J,?%' .: .
44, 4i,L . Nt.:r t %,1. !.l!li %r I'( r lr�t,'i (i+.. 1-. ... ' i It t'1 ! ,rit;
.'I/t< 1'Nil,lil{.' r+ .tit.Of, +II pill+ t/ .-11/ '/'c t/, ,1I '1't alU7l e-t/I,+I', tirrtiit,. illit 11 ' Oh f+'.,.'1 II'0/I,1f:t /i'u1!1 lilt'%ills'
Replace existing* )( , Size L_j - t x II' ',,f x H -iv
'The debris gill he disposed of at'
!meadow-tor Facility
I declare under revalue.of penurn that the statements herein contained.ire tote and correct to the hest of no knots ledge and belief I understand that.ui false ansoert st
nil!he lust cause for denial or rc.oeauon of no license and Itsr prosecution under N1(i L.Ch _Kh.Section I-
N.pplicant's Signature Date.
Owners Signature ter attachment) 1112_ ./. '444E—.
Date: L/A/Zf:)'Z4,0 _—
%Kew eil 0} Date
Budding Official for designee)
Zoning District:______
Historical District- Yes No
"Conservation re%few will be required if shed is placed within II/Oft of
wetland.20011 from ri•erfront.or located within a flood zone"
` — --i
6 24
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PLOT PLAN
FOR LOT Y
radiants loca{yZB of garage ac any building
Additions with dashed lines
sewerage disposal (cesspool)
Well or
I
- - ——
I (mot ft. rear) I
Abutter's �' I
Q I
Name
Lot i! I Abutter's
7, Name
If this is a '� 17 1 REAR YARD Lot it
corner lot, If this is a
write in R. corner lot,
name of street. write in
_ 12 1 I name of street.
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8
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SIDE YARD
moan
YARD •
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SET BALE
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(lot it fmntacx)
.\ / I 6I C2 Yl LP
(NAME OF STREET)
/ Information
/ \• Supplied by
`_: The Commonwealth of Massachusetts
•
Department of Industrial Accidents
Q. .li
, Office of Investigations
�� Lafayette City Center
_ Lafayette,1 Avenue de Boston,MA 02111-1750
sN � www.mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
— Name (Business/Organization/Individual): K i-6-.01 ,..8, j�L
j .
Address: /,3 0,0M.-e) t 2Vt_—
City/State/Zip: Phone #: sC9 -3 3 Z - 7 7
Are you an employer?Check a 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
listed on the attached sheet. 7. ❑ Remodeling
2.0 I am a sole proprietor or partner-
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. employees and have workers'
9 ❑ Building addition
[No workers' comp. insurance comp. insurance.
required.] 5. El
are a corporation and its 10.❑ Electrical repairs or additions
3. I 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' 13.0 Other
comp. insurance required.]
*Any applicant that checks box el must also fill out the section below showing their workers'compensation policy information.
I.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 herebygccertifQy under the pains and penalties of perjury that the information provi
ded above is true and correct.
X Signature: , G2leLC Z C Date:
Phone#: ,332— ' 777
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 2❑Building Department 311City/Town Clerk 4.0 Electrical Inspector 50Plumbing
Inspector 6.DOther
Contact Person: Phone#: