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Home My WebLink AboutBLDX-26-72 application Office Use Only � JUL a. 2006 Permit# 14 ii ] 1 ',0� i ::. �r` ��_ Amoun .,a�7cR \"coa ,e, BOIL TIViENT , °°RAT?i'• ay -_L__ _ 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) 398-2231 Ext. 1261 �76 lei? �Gf ✓-1'7Del/4 / 6 d P 6 7.� CONSTRUCTION ADDRESS: /� J / / OWNER: /A4(119-! tl /7.7D IV.B 5Ok P k bJ NNAAME / , / PRESENTRE DDRESS 3 2 6 av,,7/d TEL. # �y ,1 CONTRACTOR:/ //J' �CIicAD7 !?/�Oel / ✓Gr eta eAr. /20L7 e 1 /00,,, 5 / 7/ 3-v Di NAME /' MAILING ADDRESS TEL.# EMAIL: it474<-e✓► SeG�LO✓Gf 4) 640/77 GrG/f1----71e)- Residential ❑Commercial I I Est.Cost of Construction$ %/7 19' -3 P Home Improvement Contractor Lic.# /_ 2 9 35 /4134,2:6 Construction Supervisor Lic.# C$P Iq a 73 5-6S J>iyPk SHED INFORMATION / New / Size L I x W l e x H Corner Lot: Yes No V 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 7 Replace existing* Size L S" x W xx H *The debris will be disposed of at: /�f filled /2;i )'_ !) 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 vocation of my license and for prosecution� / under M.G.L.Ch.268,Section 1. yJ Applicant's Signature: [Rai '" l,� Date: /la a2 1;4.2 / Date: cJ _R 1•2 Owners Signature(or attachment) ��/"(// � CJ��' //�� Approved By: 11��—��" Date: Building Official(or designee) Zoning District: Historical District: _J 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 i _-,y�► I'` Office of Investigations am l\ •l__ Lafayette City Center —q t 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 V Name (Business/Organization/Individual): /►/7/ / :,47 A P 7)7G-7// _ Address: 570 G/ ya i✓p4v1 ��-- ✓‘''GC 2 'I City/State/Zip: /^,/ //1/ ecol), /V j Phone #: -'4? ,72--oP0 c 61 5-- 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 working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its l 0.❑ 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.❑ 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. 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 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 certifykinder the pains and penalties of perjury that the information provided above is true and correct. i J Signature: Z—/,G� rl�l'_ _ Date: Phone#: 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.❑Electrical Inspector 5DPlumbing Inspector 6.DOther Contact Person: Phone#: PLOT PLAN FOR LOT # Indicate location of Additions w dashedl or S' building Ner� disposal: (cesspool) ED eLl. oil I I -- — -- I (kit ft. rear) I 4 Abutter'sI Name la Abutters Abutter's Lot# Name Lot# If this is a U REAR YARD If this is a corner lot, \ write in V _., ..ft� corner lot name of street. �L "I" write in ` name of street. 30 a 4 RID YARD MDR YARD HOUSE p-- �.zrs p-----tee I SET BACK • 1 (lot ft. frontage) / \ / (NAME OF STREET) / \\ Information / Supplied by