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Home My WebLink AboutBSHD-26-19 Application RECEIVED �Z ��A� i..--•-_-..._-..__.____._.___- Office Use Only �Qr '� _.. . 1A yA Permit# o-� APR 2 2026 \ wN¢[EE i I R`` . .... Amount.•y'ic;,-�`RP�ORATE / ByU I L J�J_ 1'1�!" �l ACT [y� 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) 398-222(31 Ext. 1261 CONSTRUCTION ADDRESS: C r W I V �"C� 11 h ot/ OWNER:°D/41 I` A"rl.got J- Gip ' Ch L h ` oL SOV) ZCJD - C17) 1 63 NAME PRESENT ADDRESS TEL. # CONTRACTOR: NAME MAILING ADDRESS TEL.# EMAIL: M WPCS A-hi et a(14-1/1 dtt 41-0o K. ti l ,Residential 0 Commercial Est.Cost of Construction Home Improvement Contractor Lic.# Construction Supervisor Lic.# SHED INFORMATION New, ')<" Size L W /U x H Corner Lot: Yes T 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 x W x H �j 'The debris will be disposed of at \ 0 `�-_ h - >\ 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 revocation of my icense and for prosecution under M.G. Ch.268,Section I.Applicant's Signature:_& n/� • t Date: 0`T 0 1 6 F.,9wners Signature(or attachment) Date:0 V I lJ 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 • SHEDS LESS THAN 150 SQ.FT.SHAL RE PLACED A MINIMUM OF 30 FEET FROM THE FRONT LOT LINE AND A MINIMUM OF 6 FEET FROM SIDES AI' PLOT PLAN REAR LOT LINES. FOR LOT / rndicate locatica of garage or accessary building Additions with dashed lines Sewerage disposal (cesspool) WI agj _ -_ — I (lot ft. rear) I_ Abutter's Name Abutter's Lot# I(o)1 / I Lope If this is a REAR YARD corner lot, If this is a write in comer lot, name of street. 1ft write in name street. a v SIDE YARD V--— HOUSE 53DS YARD Q. _. .a.0 p-----V11 1 i • • *� c • • • I• q� SET BAGS • a Oct ft. fr Cage) , / / 6� !V9n h Act -we -i yAnmou �i- 0Z633 / (NAME OF STREET) (---- / N Infarnatlm / \. Supplied by The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ; Lafayette 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/Individuals)::, Address: i n ' f I City/State/ ip OQ X11-1\V1441 --hA Ck Phone #: J 0 P) 7)ton 10 01-- I C 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. ❑ 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.: required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.® I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.1] Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.11] 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. :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. Signature:Q GL-CU. h 4 V1 Ai- V(J Date: 0 4 l 0 / 1 � Phone#: ° Fi J b 0 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 5EIF'Iumbing Inspector 6.DOther Phone#: Contact Person: • The Commonwealth of Massachusetts 5 Department of Industrial Accidents Mho EMI 1 Congress Street, Suite 100 Boston, NM 02114-2017 rt www.mass.go v/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information PIease Print Legibly Name (Business/Organization/lndividual): 0 0 I R MUCt TLC,vC ' Address: G tiV Q h h 72 Cam- City/State/Zip: t.64 IA-44104-1 y 1b4 ®"a hone#: 5 ) 2'o - �1 �o Are you an employer?Cheek the appropriate box: Type of project(required): I.❑I am a employer with employees(full and/or part-time).* 7. ©New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in anca aci8. Remodeling Y p h'.[No workers'comp.insurance required.] 3. I am a homeowner doingall work myself. 9. ❑ Demolition y [No workers'comp.insurance required.] COI am a homeowner and will be hiring contractors to conduct all work on myto Building addition . ensure that all contractors either have workers'compensation insurance or rersole� I will 11.❑ 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. These sub-contractors have employees and have workers'comp. insurance.; 13.E]Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. I4. Other 152,§1(4),and we have no 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. 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. 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 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 do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature:9(1-(--Lt 11 a it t -t- J Date: 0 410 ! / h Phone#: "5C ' 7<i.,'�)0 " lJ 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#: