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Permit expires 180 days from
4 issue date
EXPRESS SHED PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261I SCONSTRUCTION ADDRESS: y9 r46 ci, Me 5S.e, /�Ct i 0 A 0 )6 /
OWNER: S bua.4-1- 4JUdlfji ) hi, Lit/ C'a ihrt (65A. S+ EgST --rut/nfob 14A 0271E
NAME PRESENT ADDRESS TEL. #04 0 2 o"/S
CONTRACTOR: Aire, Ivhar 0)59 QVeerg T Y)e 1� w ' Soy Ly/36 -28"4D
NAME MAILING ADDRESS TEL.#
EMAIL: we b he Q S e C40 I° CO►►'l
Residential ❑Commercial Est.Cost of Construction$ // ff OO
Home Improvement Contractor Lic.# Construction Supervisor Lie.#
/ / /^� SHED INFORMATION
New Size L `7 x W (J x H Corner Lot: Yes No
Per Town of Yarmouth Zonin.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 a. -• 'acent parcel.All sheds are required to be located thirty (30)feet 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.
Applicant's Signature: _. aiOt re Date: /2(" 2 6
Owners Signature(or attachment) ,, / C i" Date: — I 9— 2
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**
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. The Common wealth of Massachusetts
v Department of Industrial Accidents
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Office of Investigations
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• ; Lafayette CityCenter
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ValNj:iiir
-= i 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):
l
Address: 1 11 6c s s-e 40 4 d S6 (4CIA/ 6 i/
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1 / Z1 : S'ô I U( ry' lC t State/ Phone #. 0 oOY p �. �
Are you an employer? Check the appropriate box: Type of project (required):
1 . LI I am a employer with 4. El I am a general contractor and I
employees (full and/or part-time).* have hired the sub-contractors 6. LIJNew construction
2. LI I am a sole
or partner- listed on the attached sheet. 7. ❑ Remodeling
proprietor
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. employees and have workers'
+ 9. Ej Building addition
[No workers' comp. insurance comp. insurance.+
required.]
5. LI We are a corporation and its 10. ❑ Electrical repairs or additions
3. LI 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. ❑ repairs
re airs
insurance required.] 1- c. 152, § 1 (4), and we have no
employees.to ees. [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.
' 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: �— Hai 017 411 Date: — I 2 4Phone #:
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):
1 ■ Board of Health 20 Building Department 31:City/Town Clerk 4.0 Electrical Inspector 51lumbing
Inspector 6. ■ Other
Contact Person: Phone #:
PLOTT PLAN �p ('
FOR LOT # L/I ( ,,/;I i 1 6eSSG. ICJ Join YCYMOv
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Indicate location of garage or acceaacay building
Additions with dashed liras
Sewerage disposal (cesspool) ® ,—�----
Well r»
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_. ——. _ _, (1dt ft. rear) I
Abutter's I Abutter's
Name i qu d i Name
Lot# ro .ILA
c Lot#
If this is a ILI'' REAR YARD- If this is a
corner lot, corner lot,
write in , ft. write in
name of street. name of street.
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