HomeMy WebLinkAboutBSHD-26-86 application A RECEIVE ®
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Vat___ Permit expires 180 days from
issue date ra
EXPRESS SHED PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261 /_
CONSTRUCTION ADDRESS: Og1J )' Obrt I eta ç 9 a 4 H# oa(14 /
OWNER: 40 %e.-LO CS f j ctikt lam/ Lei( a0 Hivil /R. S. 41(1 m 'r/ Y)33
IME PRESENT ADDRESS TEL. # `CONTRACT vl,e_ .rbvim- aMM 9 9DD eK Ankte Q f�ar ilid.24 5 SI1--(3QaME MAILING ADDRESS EL.#
EMAIL:dInwe- °( '.0` 1
(residential 0 Commercial -Est.Cost of Construction$ Ili
Home Improvement Contractor Lic.# Construction Supervisor Lic.#
SHED INFORMATION I
New Size L rr� xW It� x H Corner Lot:Yes No
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
Replace existing* Size L x W x H
*The debris will be disposed of at: L.)
a_,r ott4�`
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 deni wocation of y license for pro ution under M.G.L.Ch.268,Section 1. (� �1
Applicant's Signatu : l /Date: — p(S—g&
Owners Si natur or attachment it Date:
Approved By: Date:
Building Official(or designee)
Zoning District:_
Historical District: LI Yes 70No
**Conservation review will be required if shed is placed within 100ft of
wetland,200ft from riverfront,or located within a flood zone**
6/24
4
I
The Commonwealth of Massachusetts
-- Department of Industrial Accidents
Office of Investigations
__=
'� Lafayette City Center
. r 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): , ) jtt,v L L..-6 W� e
Address: ap P(1,,(2 r (a,i,u
City/State/Zip: S, (.raw 1g 0-W Phone#:_5Qg' 116
pti- i
Are you an employer? Che k the appropriate box: Type of project(required):
1.n I am a employer with 4. ❑ I am a general contractor and I
6. New construction
employees (full and/or part-time).* have hired the sub-contractors
listed on the attached sheet. 7. ❑ Remodeling
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. ❑ Building addition
[No workers' comp. insurance comp. insurance.t
required.] 5. 0 We are a corporation and its 10.❑ 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.❑ Roof repairs
insurance required.] t c. 152, §1(4),and we have no
employees. [No workers' 13.❑ Other
comp. insurance required.]
*My 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 hereb ' under the pains .pen Ities of perjiny that the information provided above is true and correct.
Signs e: '.--- V f i4_ 444?-1' Date: ?"—a51-42
Phon • (50 r—77i, NO/ 7 7 y.- r - X72,35
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 3❑City/Town Clerk 4.0 Electrical Inspector 5pPlumbing
Inspector 6.0Other
Contact Person: Phone#:
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PLOT PLAN
FOR LOT #
Additiorer with location
of or accessory
building
Sellers dispel (cesspool)
gr4
I I
— — — — I (lrit ft rear) I
Abutters �\� Lome
1
Name ��,;^ i Abutters
Lot# ,{1I
Lot#
If this is a REAR YARD It this is a
corner lot,
write in R corner lot,
name of stree write in
name of street.
I
y J
SIDE YARD
HOUSE SIDE YARD •
•
•
•
•
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SET RACE •
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. 4 f R.
40.
•
(lot ft. frontage)
\ /
\ / (NAME OF STREET)
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• Supplied by