HomeMy WebLinkAboutBSHD-26-101 application 1
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"`' 47 BUILDING DEPARTMENT Amount `3C0Z/
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'y��RPO ft01,, Permit expires 180 days from
issue date
EXPRESS SHED PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28
South Yarmouth, MA 02664.. _
(508) 398-2231 Ext. 1261
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CONSTRUCTION ADDRESS:_._ I L. '-lo4pv/vA Pa SUUT'laVAdeisaarri /irr
OWNER: S 004 a4 VO'-pc a 2 -raii-o►NA of? lothvi T/ 5-og g LU / f t 8
NAME PRESENT ADDRESS TEL. #
CONTRACTOR: //�►�
NAME N 1\II.ENG ADDRESS TEL.#
EMAIL: 76g►N ( Vo(A . (-71/141.74-y
Residential 0 Commercial ❑Est.Cost of Construction S Z 0 00
Home Improvement Contractor Lie.# Construction Supervisor Lic.#
SHED INFORMATION
New X Size /. I Z x W 5 x H v Corner Lot:Yes No k
Per Town of Yarmouth Zonint;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:
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 revoc f my license and for prosecution under M.G.L.Ch.268,Section 1.
Applicant's Signature: Date: IO//(fZC)Z,
Owners Signato r 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**
ft 24
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Lafayette City Center
—I 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): O 6 PV VoG9G
Address: (Z- T oA4,v M4 pR
City/State/Zip: S. V8ieOLC/t'I MA Phone#: St)8 826
Are you an employer?Check the appropriate box: Type of project(required):
1.❑lam a employer with 4•❑I am a general contractor and I
employees(full and/or part-time).*
have hired the sub-contractors 6. l.New construction
listed on the attached sheet. 7. ❑Remodeling
2.❑I am a sole proprietor or partner-
ship and have no employees These subcontractors 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.[X 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 12.0 Roof repairs
insurance required.]t c.152,§1(4),and we have no
employees.[No workers' 13.0 Other
comp.insurance required.]
'''Any applicant that checks box ql 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 subcontractors and state whether or not those entities have
employees.If 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 insurance coverage verification.
I do hereby certi er the pains and penalties of perjury that the information provided above is true and correct.
Signatur. Date: /00 S7702 S�
Pn' . Sda �s 2G 9 !R
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 30City!rown Clerk 4.❑Electrical Inspector 51:Plumbing
Inspector 6.0Other
Contact Person: Phone#:
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PLOT PLAN
FOR LOT #
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Thdicate Adclitices with dues of garage or accessary building
Welleage disposal (cesspool) Ea
l o I
Ic 2 ft. rear)
___. ..._ I
42,s47p is ----- -- -- A , 'I
i Abutters,,, 'ry 941er's 7a A Name f^i Name
Lot# v_. .3-60, *,41. Lot# ZO To ^1
If this is a REAR YARD If this is a
write pcorner lot, 73 ft• corner lot,
name of street. write in
f -
name of street.
I . ),(G.0 . . 4:>
SIDE YARD) SIDE YARD •
•
- HOUSE /� �!
M • r :
r -•
r
•
SET SAO( •
�.. 0 :
i
1
(20t 1 Zs--- ft. mot )
A
�/ 'Z-� An4- Die
/ (NAME OF STREET)
/ Information
`. Supplied by
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Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual, partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for'any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary, supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s) of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Lafayette City Center, 2 Avenue de Lafayette
Boston,MA 02111-1750
Tel. 6 7( 1 ) 727-4900
00 or 1-877-MASSAFE
Fax(617) 727-7749
Revised 7-2019
www.mass.gov/dia