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1///S". 6� issue date
RECEIVEDI
E PRESS SHED PERMIT APPLICATION
APR 17 2026 TOWN OF YARMOUTH
Yarmouth Building Department
1 f R ENrar 1 146 Route 28
tt South Yarmouth,MA 02664
(508)398-22311 Ext. 1261
CONSTRUCTION ADDRESS: if/ 147 r44.51 .l3D"I o 'e e u e.r C74.--s-r/e4 f N/d 4(7/-/ AIA- 62673
OWNER: /14Q44 —57..Fq 4 ,534"M� As(-Lout 57C 30Y I/2t 7
_._.._TEL.u
NAME PRttil NT\DURPSS
HAR6ol2-1/l--"jI- 5/1CP 326 `hota1e7F! 6 Nei/t^+d� f' 77/ 7070
CONTRACTOR: �- -...
N:M\ME ---- MOILING 4DURI'SS TEL
EMAIL:k1 nn 15e p'Ae 410r.•Co.0
esidential _Commercial Est.Cost of Construction S 106' 00
/ y_
Home Improsement Contractor Lic.# Construction Supervisor Lic.#
/ SHED INFORMATION
New t/ Size L o 'LW (0 x H Corner Lot:Yes_ No
Per loon at)annuullt/.oiling Br-Lare See 2113.5 Note E:
Ohl,'Jrhl r,to tort!„crh,n k,1,,rII, r„nn 1'rril,l1RQ,,„nl<uuinu„it'lrtnr,ht'/lilrt ,l501,ytt,tr,./r,'I,II It's, at,l sirl¢lr sDuff.
/i,111, to .1,,I,c/In all,htn r,Is bird II:ii , r 4,011 sill,',n t r„ur t hrnl,prrs /1,hal/i ItIser llrwr rtt di r,l',!cc,i,,ant
,ill, hnd lirr,e„u,ill,r,lhrr,ru faun,l 1ll,Arils a-s'r,,IIIII0 J l„hr twirled thrill i ittr pi'etjr,mi ynn/rtnu Lit!it),
Replace existing*f>7 Size L x II' x II
'The debris will he disposed of ai -
Location of Facllltg
I declare under penalties of Noun that the statements herein contained arc true and correct to the best of my Imou ledge and belief I understand that am false answensi
x ill be lust cause for denial or re,ocation of my license and for prosecution under M G.L.('h.2611.Section I.
Date
•tpplIc
Owners i Signature !/ ' - L,!
Owners Signature Inr attachment) Date: -//l�/�10Z44.
Dale
\ppm,cd tic
Building Official I or designee I
Zoning District:_
Historical District Yes a
••Conscrsation ree iew will be required if shed is placed within 1000 of
wetland.200ft from riserfront.or located within a flood zone^
b 24
�,Y\0.C-V\CCCv1e 1 C(' .
THY'
.
•
SHEDS LESS THAN 150 S FT A.Li
RE PLACED A MINIMUM 30 F CT
FROM THE FRONT LOT LINE AN A
PLOT PLAN MINIMUM OF 6 FEET FROM SIDES AND
REAR LOT LINES1
(,i
FOR LOT t
kndicata location cif garage
SewerAdditi w hed lima o- accessory building
age
Well disposal (cesspool) 6
to
— _ I (1s t....6..... .ft. 1
)
Abutter's
Name
Lot I Abutter's
Name
If this is a Lot#
REAR YARD
corner lot,
write in If this is a
name of street. •••-•• ..ft. comer lot,
.• write in
name of street.
. 'a 4
4 -a
6 t c4
SIDE YARD
•
•
: d—— y X; f> HOUSE
YARD
.
•
•
•
••
SET BACK
_ft. :
i
(lot..... .... ........ft.
1 1 ,� frontage)
` / l VlQ N�
\ EE (NAME OF STREET)
/
/ \ Infarmat;icn
si/pplied by
, The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
"1
' a al= 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
Q
Name (Business/Organization/Individual): i ?"./ AIR t',o.4 �r`,e v
Address: 32.6 , +-Ke467.47H /2_,F),-n /f*kiwis .
City/State/Zip: iVi-3- - o 6 al Phone #: -J,g �3 in 5 _
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
* have hired the sub-contractors 6. ❑ New construction
employees (full and/or part-time).2.❑ I am a sole proprietor or partner- listed on the attached sheet. ?• 0 Remodeling
ship and have no employees These sub-contractors have 8. 0 Demolition
working for me in any capacity. employees and have workers' 9 ❑ Building addition
[No workers' comp. insurance comp. insurance.
required.]
5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3.0 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 12.0 Roof repairs
insurance required.] t c. 152, §1(4),and we have no 13.0 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.
Q 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: pci'? Date: "1" 2°26
Phone#: 516 - 3 0 4 -- Y .87
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 3c1('ity/Town Clerk 4.0 Electrical Inspector 50Plumbing
Inspector 6.0Other
Contact Person: Phone#: —
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