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HomeMy WebLinkAboutBSHD-26-87 r 40 Y � RECEIVED !T Office Use Only g �� Petmit# SI)17`a(o—g7 o _ �yyy,,� AU6 2 6 2026 — ' ' 1 3 Amount 3 s wwiY.kt4� '. N Wiz"`" Bs}!l D3hi Permit expires 180 days from BY c�/l-e C K 51.7 o issue date EXPRESS SHED PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 �/ L (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: -/ 7 J Li / P�D L fi v . Vf9/<LtTTE F4.7/i‘.1 revs r 97Si.F`a 4ve, OWNER:/67At/L, VN"& rre Tetwee 1e,y/02m rr/rbe /724- 7 7'1 of%S-../J53 NAME / PRESENT ADDRESS p d 6 73 TEL. # CONTRACTOR: NAME MAILING ADDRESS TEL.# EMAIL: PXVA>«E-r-r.c G/VAic; Ccm Residential 0 Commercial Est.Cost of Construction$ / CMG 0 ! Home Improvement Contractor Lic.# Construction Supervisor Lic.# 6 SHED INFORMATION 1 New I, Size L /c)- x W /0 x H /U Corner Lot:Yes f/ 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)feetfroin any front lot line Replace existing* Size L x W x II *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: Date: J Owners Signature(or attachment) � i7 Date: e:74 Approved By: Date: Building Official(or designee) Zoning District: Historical District: If Yes ! No A **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 _1 1* of Investigations ,mmtioiN~A) 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): /.) U L x , �/�/L LL r-TZ/ 7-41 le- Address: City/State/Zip: Phone #: 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 10.0 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.] *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 hereby certi under the pains and penalties of perjury that the information provided above is true and correct. Signature: -�Gi�j�• Date: 8/a1 G�a?G Phone#: 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 3❑City/Town Clerk 4.0 Electrical Inspector 5.EIPlumbing Inspector 6.0Other Contact Person: Phone #: 1.-u 1 bb-`( 18 OLK AVENUE SUFF - +y1CH POINT ELEV=71B W Q o G 3g. / � LOT 19 i • / CONC. T.F FOU_7 D. `o I a �� LOT 18 \X o „� 17,958 + S.F. '� 'y (0.41 ± AC.) o o, 98 n 1 2tr' LOT 25 NOTE : TOP OF FOUNDATION 1 S 22 ABOVE THE BIICH POINT OF THE ROAD. JOB # 94-037 L18 — • CERTIFIED PLOT PLAN PREPARED FOR : LOCATION : ASES MAP 66 PAR Y18 SUFFOLK AVENUE YARMOUTH SCALE : 1" = ;;' REEF REALTY REFERENCE : LOT 18 PLAN BOOK 432 PAGE 96 ~' I HEREBY CERTIFY THAT THE STRUCTURE ti C}'�i �4. SHOWN ON THIS PLAN IS LOCATED ON THE ��`in GROUND AS SHOWN HEREON. Cci+�lfif:STCD -1 t No.CCr��� v, DM �1,y � DEM4REST - McLELLAN ENGINEERING z'%;yr;nIV''fq 24 SCHOOL STREET P. 0. BOX 463 SEPT. 29, 1994 WEST DENNIS, API 02670 (508) 398-7710 DATE RO SIONAL LAND VEYOR — REVISED I � 6: SEPT. 30, 1994 \`_�"'�- 5„ Ncc, MAP 0— I