HomeMy WebLinkAboutBLD-21-000582 XaR O. ice Use Only
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EXPRESS SHED PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261 \^
CONSTRUCTION ADDRESS: d/ yG yl , JO t ?Car'01 € , 1
ASSESSOR'S INFORMATION:
Map: g Cf e j / Parcel: 81 L j S
OWNER: �/C{ r)y v�l a 2 l Gt y Gr( c,rr'� C Q t ��(�, v 1 �J� 5��f �a � DS l
PRESENLADDRESS ' TEL. #
CONTRACTOR:
NAME MAILING ADDRESS TEL.#
l� Residential ❑Commercial Est.Cost of Construction$ S Q O C)
Home Improvement Contractor Lie.# AJ/4- Construction Supervisor '
Workman's Compensation Insurance: (check one)
E J V E r l
am the homeowner I am the sole proprietor I i I have Worker's Compensation nstanc9`41'� /i/
Insurance Company Name: X/A Worker's Comp.Poli • AUG 2QZC '
SHED INFORMATION y G_ �' D yH
New 1. Size L / U x W o x H , 2. Corner Lot:Yes 7 No
Per Town of Yarmouth Zoning By-Law Sec 203.5 E:
Side and rear setbacks for accessory buildings less than 150 square feet and single story, shall be 6 feet in all districts, but
in no case built closer than 12 feet to any other building.V
Replace existing* Size L iO x W �5' x H l 2
*The debris will be disposed of at: Q 0jt 4 4 G/7 ci 7 ,`7/
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 revocatiop of my license..d for prosecution under M.G.L.Ch.268,Section 1. l
Applicant's Signature: < ♦ Date: 7 / 3 /� 6
Owners Signature(or attachment) 4' ! / e Date: 7 J� 6
Approved By: _ Date:
Building Official(or designee) EMAIL ADDRESS:
Zoning District:
Historical District: I Yes No Flood Plain Zone: Yes i No
Water Resource Protection District: Within 100 ft.of Wetlands:***
I_ Yes I No I Yes No
***Note:Conservation review required if within 100 ft.of Wetlands
9/13
The Commonwealth of Massachusetts
Department of Industrial Accidents
FllilB_2 1 Congress Street,Suite 100
Boston,MA 02114-2017
www.mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Leeibiv
Name(Business/Organization/Individual): /Ctlt7 fl y c/plt"t Z .p j,(c -"I cat r 7 .- 1,Ir_J1 t-J 5
Address: 27 //a r ii hq Li, /t 25f.-
City/State/Zip:4). Yg rod�� G z4,7 3 Phone#: Y („d 6'ro
Are you an employer?Check the appropriate box: Type of project(required):
1.0 I am a employer with employees(full and/or part-time)." 7. New construction
2.0 1 am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling
any capacity.[No workers'comp.insurance required.]
3.r2 I am a homeowner doingall work myself. t 9. Demolition❑
yse [No workers'comp.insurance required.]
4. I am a homeowner and will be hirin contractors to conduct all work on10 El Building addition
❑ g my property.I will
ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
proprietors with no employees.
12.❑Plumbing repairs or additions
5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.❑Roof repairs
These sub-contractors have employees and have workers'comp.insurance.: Ch
6.0 We area corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other V
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
"Any applicant that checks box S I must also Sll 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 I�
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 MGL c.152,§25A is a criminal violation punishable by 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.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: mil, • C Ulm told>^i c� c c) Date: / �a Z 0
Phone#: Sa&- (p 9 Lj/ Vv(p bs`/o
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
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Additions with dashed lines
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