HomeMy WebLinkAboutBSHD-26-53 application RECEIVED
I JUN 2 2 2026,�. � I i Office Use Only
'�EA � O: 22
�. Permit# 3��t7—�tag✓
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Permit expires 180 days from
issue date
EXPRESS SHED PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664
2 (508)398-2231 Ext. 1261
CONSTRUCTION ADDRESS: v 7 e?bb1j e
Begs, tthy._
OWNER: ilsa + NM- U kite �/L ItPelec.UI ( 304 / 3
NAME PRESENT ADDRESS TEL. #
CONTRACTOR: D OW
NAME MAILING ADDRESS TEL.#
EMAIL: M C/ 61-40Y,
Residential D Commercial _ Est.Cost of Construction$ / 00 .D
Home Improvement Contractor lie.# Construction Supervisor Lie.#
SHED INFORMATION V
New / Size L /U� x R' f x H Corner Lot:Yes No
>�
Replace existing* Size L. x If' 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 I.
Applicant's Signature. Date: /,, n n /,
Owners Signature(or attachment) '' Date: (!//!� - ono 02t('
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
1
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PLOT PLAN
FOR LOT i /577Z
nsiicate location of garage or accessary building
Additions with dashed lines
Sewerage disposal (Cesspool)
Well egi
Hb I
(hit ft. rear) l
4 lkoPt
Abutter's � Abutter's
Name Name
Lot# ( Lot#
If this is a REAR YARD IQ'
If this is a
corner lot corner lot,
write in ft. write in
name of street. name of street.
)
•
✓f+' l ail
MDR YARD SIDE YARD •
HOUSE
a-----1'0 I/O•
•
•
•
•
SET BACQ
(lot llD ft. frontage)
•
3? Pcbb/ h tt) ,
\ / (NAME OF STREET)
Inftestatlat/ `\. Supplied by WAIL AIL lbu ee,1 f�rCCl�(-Q
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 np AA f Please Print Legibly
uV,p'
Name (Business/Organization/Individual): V � ' — -1—g' CX�I4
Address: P -bl-7l
City/State/Zip: S- Ytt-c V/t- .& ,fl\ } 1/Phone ft: 60/7 -5V --‘0 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
employees (full and/or part-time).* have hired the sub-contractors 6. ❑ New construction
listed on the attached sheet. 7. ElRemodeling
2.❑ 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. 0 Building addition
[No workers' comp. insurance comp. insurance.:
yrequired.] 5. 0 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 12.0 Roof repairs
insurance required.] ' c. 152,§1(4),and we have no
employees. [No workers' 13.0 Other
comp. insurance required.]
*My 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. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I ant 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 surance coverage verification.
I do hereby c erti urn'er the ,ai s and penalties perjury that the information provided above is true and correct.
Signature: • Date: lSi/_.; , -- //-2()
Phone#: d:V 7 — aV e? _� 5
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 2❑Building Department 31:City/Town Clerk 4.1=1 Electrical Inspector 50Plumbing
Inspector 6.0Other
Contact Person: Phone#: —
J,
MORTGAGE iNspEcTioN PLANi :1
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Applicant 17 ow;iord0t,le Location: yw 0,-/-fig s`
1 (1)
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Lot L53
Rt. c\wl".)‘
\ \
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411.-
ram 00* \ \ \
"Trio ell ed w �� \
L10 137 peg- p tam \ \
\ \
\ \
o1 o
\ \c1:)
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L - 2stUro
Lot
1 s 2.• rS) I
(,otL28 f
1(0, 0 ,
tot i,51
in
�� PAUL '6
let
Title ref: 167228 Mood Panel: 25001 Co 5q1 f od Zone: X i DROVER t_, V,
9 hereby certify that this mortgage inspection was prepared for . \ %# 31 -a
A . /, itt _e/twt17. Fi eg..sWyr s • w�
The dwelling shown hereon does rat fall in a special 5.E.M.7q. flood zone 1,: J i°y.__ /-;'°'
A or V , with an effective date of 7-16-14-- and the location of the dwelling .
o conform to the local zoning by-laws in effect at the time of Scale: 1"= 4O '
construction with respect to horizontal dimensional setback requirements Date: 8 - 24- 2L
or is exempt from violation enforcement action under/G.L. Ch. 4074, sect.? Jile No. Zi- 15 3 I
Please note: The structures shown on this mortgage inspection are shown approximate only: 4In instrument survey is necessary to
determine a precice location of structures and property lines. This mortgage inspection must not be used for recording purposes or for
use in preparing deed descriptions and must not be used for variance or building department purposes. Verification of building locations,
propery line dimensions,fences or lot configuration can only be accomplished by an accurate instrument survey which may reflect different
information than what is shown hereon. NOTE: THIS IS NOT A BOUNDARY SURVEY AND IS FOR MORTGAGE PURPOSES ONLY.
COLONIAL LA\ D
SURVEYING COMPANY iNC.
POST OFFICE BOX 350 • HLIMAROCK, MA 02047 • P: 781-826-7186 • F: 781-826-4823 • E: COLON1ALSLIRVEY@GMr\IL.COM
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