HomeMy WebLinkAboutBSHD-26-94 application YA
Office Use Only
- 41 Permit#(?'
Amount
Permit expires 180 days from
issue date
EXPRESS SHED PERMIT APPLICATION
TOWN OF YARMOUTH
GEIVED
Yarmouth Building Department ' "
1146 Route 28 26
South Yarmouth, MA 02664
(508)398-2231 Ext. 1261 I l �
BUILDING
31 ice house rd BY
CONSTRt'(T101.�DDRESS: ---- _— `
OWNER: Peter Colgan 31 ice house rd 508-308-5546
NAME PRESENT ADDRESS TEL. #
CONTRACTOR:
NAME MAILING ADDRESS TEL.#
EMAIL:Plcmillis@gmail.com
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0 Residential 0 Commercial Est.Cost of Construction S V CD
Home Improvement Contractor Lic.# Construction Supervisor Lic.#
SHED INFORMATION
New Y Size L 8' :W 5 5� i H $� Corner Lot: Yes No N
Per Town of Yarmouth Zoning Br-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)feetfrom any front lot line
Replace existing*No Size L x W x H
'The debris will be disposed of at:
Location of Facility
[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 r ation y lic and\)prosecution under M.G.L.Ch_268,Section 1.
Applicant's Signature: Lc�✓ Date. 97C0/7
Owners Signature(or attachment) Date:
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"'
6/24
The Commonwealth of Massachusetts
1i _ Department of Industrial Accidents
- 1 Office of Investigations
i-; ' 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):/ /� � Leif
is 2 i
Address:_ 'c i / __ /-74v,/S� (C.ck.
City/State/Zip:Sr 4 v- ev irk. t4 o`_ Phone#: c,'c 5- 3 ti 4,
Are you an employ ?Check the appropriate box:
1.❑I am a employer with 4. ❑I am a general contractor and I Type of protect(required):action
employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
P )
2.❑I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. employees and have workers'
[No workers'comp. 9. 0 Building addition
insurance comp.insurance.:
ired.] 5.0 We are a corporation and its 10.0 Electrical repairs or additions
3. qu
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.]' c.152,§1(4),and we have no
employees.[No workers' 13.0 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. II the subcontractors 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 ranee co'ge verification.
I do hereby ee ';� r ,t es t perjury that the information provided above is true and correct.
i_nature: ///f 41111 Date: l
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):
l❑Board of Health 20 Building Department 3❑Cityffown Clerk 4.0 Electrical Inspector 50Plumbing
Inspector 6.❑Other
Contact Person: ___ Phone#:
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PLOT PLAN
FOR LOT )y
indicate lncatico of garage or accessary building
Addificas with dashed lines -------------
diapoeai (cesspool)
N •
-- — -- — (itht. ft. rear)
irk
Abutters r COAbutter's
• Name ',
Lot# S Name
Lot If
If this is a S,3`
corner lot, fi• 8 ( , If this is a
write in �' corner lot,
•••• write in
namename of street.
of street.
j
t3 • .0
t
SIDS YARD :
SIDE YARD •
NOOSE
•
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•
•
SET
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EA=
.i .
(lot ft. t )
•
kee
/ (NAME OF STREET)
Infarmatlat
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