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HomeMy WebLinkAboutBSHD-26-97 applicaiton (ój RECE1VEDOffice UseOnly i O� O. s� y (� C Permit#6tAD-A—ci 'f ,.ir. SEP 3 Zo2� Amount 35 ,.,.1,:t t �� B U I D Permit expires 180 days from ''+o.�._ PA R T M E N T By issue date EXPRESS SHED PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth, MA 02664 / (508) 398-2231 Ext. 1261 CONSTRUCTION ADDRESS: /34 CR Q 1y6 a°C-t- ci oL ta.n —. 8 t°4 Pe,--tar 'fL td e s ��s 7 ct$3 •9746 OWNER: p a.bDv-e.. AME PRESENT AD SS TEL. # CONTRACTOR: J� NAME �, , MAILING ADDRESS TEL.# EMAIL: 6 f4,4C-S d a 67 gi rtiQ� , 29.fiz- oleesidential 0 Commercial =Est.Cost of Construction$ b Q .a a Home Improvement Contractor Lie.# Construction Supervisor Lic.# SHED INFORMATION / New 7 Size L 14 x W tot H #J0" 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)feetfrom 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 li or prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: 1� Date: q`'3b vx2,21:3 Owners Signature(or attachment) . Date: R"33 t,'.0)'..b 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 Department of Industrial Accidents i- — _ Office of Investigations Lafayette City Center _: 2 Avenue de Lafayette, Boston,MA 02111-1750 s • www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Tae--A1 ain-t,L Re±LS___, ,E'L.d1-.i ell :J Address: 730 Cr LL/2,h-e 1-"Iv 0/-.ea-n e_ City/State/Zip: So _ .z� Phone #: YJ• '? b 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. ew 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' [No workers' comp. insurance comp. insurance.# 9. ❑ Building addition fired.] 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 11.0 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' 13.0Other 7.2 Alt‘Sh e.cL 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 certify under the nd penalties of perjury that the information provided above is true and correct. Signature: Date: Phone#: 7 1 .5.3- . ic3A Official use only. Do not write in this urea, to be completed by city or town official. City or Town: Permit/License # Issuing Authority(check one): 10Board of Health 20 Building Department 3.0City/Town Clerk 4.0 Electrical Inspector 50Plumbing Inspector 6.00ther Contact Person: Phone#: PLOT PLAN FOR LOT Y AI Indicabs Additions with dashed of garage or urwre--y building e1 �Sewerage er disposal (cesspool) Es 1 !� I I - - - -I (Iat 1123 ft. ) I Abutter's I I so Abutter's $ �7hdAle- Nameq Name Lot# d I laAY J b3` Lot am#� t)lu2A. It this is a REAR YARD If this is a corner lot, comer lot, write in 1 ft. write in name of street. name of street. I CI w7 L411� o 'i 1 4 SIDE YARD SIDE YARD • NOOSE ' ( 0---7— .a.0 p-----ETA Ck 1 1 • SET Mat • • (lot i l.O.......ft. frontage) • \ 1/ /30 cRiciiv st-ry y ._ zr \ / (NAME OF STREET) / \ Information L / \. 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