HomeMy WebLinkAboutBSHD-26-54 application fAr4i RECEIVED ;
/'O -�' '4/�irt, — ()Rice Use Only
° ;_ 64 JUN 22 2026 ' . Permit# *t•"—ac. -?'i
tc 4',- Amount
~•'42-R °!!'. '°�%' BU I I N Permit expires 180 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: 40 Briar Circle, South Yarmouth
OWNER: 40 Briar Circle Realty Trust. 147 Drexel Drive Severna Park, MD 21146. 410 353 5995
NAME PRESENT ADDRESS TEL. #
CONTRACTOR:
NAME MAILING ADDRESS TEL.# .
EMAIL: vahlberg@comcast.net
❑Residential ❑Commercial CIEst.Cost of Construction$
$11,000
Home Improvement Contractor Lic.# Construction Supervisor Lic.#
SHED INFORMATION
New X Size L 8' x W 14' x H Corner Lot:Yes No X
Per Town of Yarmouth Zo hw By-Law See 203.5 Note E:
Side and rear yard setbacks jor•accessory buildings containing one hundred fifty(150) squareJ'et or less and single s/arc.
shall be six(6),feet in all districts. but in no case shall said accessory buildings be built closer than twelve (12)feet le)and
other building on an adiacent parcel.All sheds are required to he located thirty (30)Ji ei from any front lot line
Replace existing* 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 revocation of my license and for prosecution under M.G.L.Ch.268,Section 1 a .
Applicant's Signature: J�Ah t V � Date: C . a , 1O2 (.
Owners Signature(or attachment) ./z�cAs• v T/ c C Date: 944/1.24_ e2. a 0 .. 4.
c.
Approved By: Date:
Building Official(or designee) 1
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
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/Individual):7i/ 3 iC/4,-. //sec Q61.CT vfia 4 AV/A
y TRUST- YRftc Bf/tt-t—rTFF
Address: /�'f-7 E-L 7)A.
City/State/Zip: SEt/E, 41-PAAZ J�?yj 2W Phone#: Lf'*/0 - 33-3-Nr9 qS
Are you an employer? Check the appropriate box:
❑ I am a general contractor and I Type of project(required):
1.❑ I am a employer with 4.
employees (full and/or part-time).* have hired the sub-contractors �' 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
working for me in any capacity. employees and have workers'
[No workers' comp. insurance comp. insurance.t 9. El Building addition
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.NI 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
employees. [No workers' 13.10 Other 5-WAS-7,
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: ,th,61. _
Date: 9,1 ,
Phone#: Ai/e 3,5 3 19 9 '
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):
1DBoard of Health 20 Building Department 30City/Town Clerk 4.0 Electrical Inspector 50Plumbing
Inspector 6.DOither
Contact Person:_ Phone#:
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