HomeMy WebLinkAbout2015 Jan 02 - Sign Off Transmittal Sheet, Floor Plans, Bldg. App. .,,_ _ _ _ _ ,...,,A,�.,.,.,�_. _ __ _ _ _ _ �
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�o!�;�'��,� TOWN OF YARMOUTH �
� `,���� HEALTH DEPARTMENT +
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��'''•�N�-``� ' PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET '
To be completed by Applicant.• �
Building Site Location: a /yQ,» ��t. Qr,,,,�f f����.�. ��. o�.d � S (
Proposed Improvement: ,��,,,a,;,. o� �;[,�a, /�iy7�,s�� ;,,, ,.,�.; '
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Applicant: �f o„�,� �,�,��c^�r��.�/ Tel.No.:�,�g -.��s'.2-�✓�"6 � '
Address: � /�G.'„ �5�. �,,.,,,a������ �� ��6 �-S" Date Filed: a � �—
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**Ifyou would like e-mail notification ofsign off,please provide e-mail address: �
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Owner Name: �f�.,��� .-�f �c-� �
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Owner Address:�b �� u,� �T s��f� Owner Tel.No.: �-
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� RESIDENTIAL AND/OR COMMERCIAL BUILDING
HEALTH DEPARTMENT: Determines Compliance to State and Town Regulations; i.e., Requirements �
For Septage Disposal and other Public Health Activities.
Please submit three (3) copies of plans, to include: !
(1.) Site Plan showing existing buildings, water line location, ,
and septic system location;
(2.) Floor plan labeling ALL rooms within building ;
(all eacisting and proposed) — ;
Note:Floor plans not required for decks,sheds, windows, roofing; ;
(3.) If necessary, Title 5 application signed by licens�d installer �
with fee. ;
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REVIEWED BY: � DATE: 1 �` J � � �
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PLEASE NOTE ;
COMMENTS/CONDITIONS: I
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.- � oF•rqR BUILDING PERMIT APPLICATION
, � '�"Q APPUCATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE,OCC:UPANCY OF,
oy OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELL(NG.
Tc��vn c>f'1i►r�noiith Btiilding Dt�p�irt�tirtlt
�MATT.►C'1[[3 �
`�-.�,••*�Ca' I 1-�fi Rc�ute _�� • lar�ircnuh. �[:1 0`�Ei6-�--�-��1`L •
Tei: 508-398-22,31 e�� 1Z61 Fa�[508-398-0836
Office Use Qnly Planninq Board informatio� Assessors Department Information: J
P@RTitt N0. DBiB Plan Type Map �or
Permit Fee $ Endorsement Oate /
Recording Oate New
Deposit Rec'd. $ Date plan No. 1.4 Property Dimensions:
Net Due $ Other lot Area(sf) Frontape(tt) Lot Coverapa
This Section for Oiftce Usa an
Buiidin Permit Number: Date Issued:
Signature: Certificats of Occupancy
Building Offici�l Date is is nol required
Section i - Site InfoRnation
1•1 Prop�rty Addross: 1.2 Zoning Information:
L /�.-.r, 'S'�_ .rr.�tiv..s..t�,.-��.,...� /C�
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- �ab�� Zoning District Proposed Use
1.3 Building Setbaeks(ft) �
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.4 WatK s�pph(M,O.L e.40.S 54� 1.5 Flood Zone(nfortnalion; Commentx
Public Private Zo��; g�
Section 2- Property OwnershiplAuthorized Agent
Z1 Own�r of Reeoed:
�f�aNu..4/��r��� � �,' G`3.Z �S
Name(print)�
Mai ing Address:
S�,���_��� .?A�•36y-.zy6 � -y a
g ature Telephone Telephone
2.2 Authorized Agent:
Cr��ai9 Address: �
G�7 �' c� �+ � �
✓
Nan�(p�int) Mailing Address:
.
...._, .r�•3�.sr�ay�� s �- so
S�gnature Telephone F�
E��ai4 P�dda•ess; j
Section 3-Construction Services
3.1 Ue�ns�d Coestruetlon Sup�rviso� Not Applicable ❑
_ c Y'P!�J G' /J'
License Number
Addres / v ��'��
/ ��5 - a � ���
/ � _ Expiration Date
an,re re�epnon Era�ai9�,ddress: � � S�—
1 oi 4
OVER
Section 6- Description of Proposed Work(check ati applicabte)
� • New Construction ❑ (for muitipi i�y oniy) No.of Bedrooms (for multiple family oNy) No.of Bathrooms
Existing Bldg. ❑ Repair(s) Alterations ❑ Addition 0
Accessory Bidg. ❑ Type Demolition , Other Specify: .
Brief Description of Proposed Work:
.
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Section 7- Use Group and Construction Type �
Building Use Group(Check as applicapable) Construction Type
A ASSEMBIY � q.t � A-2 � A-3 � 1A ❑
A-4 Q A-5 � 1 B ❑
B BUSINESS f 2p, �
E EDUCATIONAL � Zg �
F FACTORY Q F-1 � F-2 � 2C �
H HICaH HAZARD � 3,q �
I iNSTITUTiONAL � 1-1 Q I-2 � I-3 � 3B ❑
M MERCHANTILE � q �
R RESlDENT(AL Q q-1 � R-2 � R-3 I] SA ❑
5 STORAGE � S-t � S-2 � 5B ❑
U UTILITf � SPECIFY:
M MIXED USE � SPECIFY:
S SPECIAL USE � SPECiFY:
Complete this section if existing building undergoing renovations:additions and/or change in use.
Exisqng Use Group: Propased Use Group:
Existing Hazard Index 78d CMR 34 Proposed Hazard Index 780 CMR 34
Section 8 Building Height and Area
Buitding Area Existing(ii applicable) Proposed
Number of 0oors or stories
induda basement levels
Floor A2a per Floor(sf)
Total Area All Floors(sf)
Total Height(ft)
Section 9- STRUCTURAL PEER REVIEW(780CMR 110 ft)
Independent Structural Engineering Structurel Peer Review Required Yes.......... No..........
SECTION 10a OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
�� —��" n� ��f s� , as Owner of the subject property,
hereby authorize _ �f�,�i o �r r,� � to act on
my behalf, in all matters relative to work authorized by this building permit application.
/�.? /,5�
S�gnature ot Owner Date
3 ot 4 OVER
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, , , . SECTION 10b OWNER/AUTHORIZED AGENT DECLARATION �
�� �' C�''�� � � , as Owner/Authorized Agent �
hereby declare that the statements and infoRnation on the forgoing application are true and acurate, to ,
the best ef:ry kne���lsd�s and helie{,
Signed under the pains and penalties of perjury.
�7�G N� "/--�YG'��d�I .
Print ame
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Signature of Owner/Agent Date
Seciion 1t - ESTIMATED CONSTRUCTION COSTS
item ' Estimated Cost(Doltars)to be
compieted by pertnit applicant
t.Building
,��5,'0 00 ----
2 E�ecmca�
3.Plumbing/Gas
4.Mechanlcal(HVAC) �
5.Fre Protection
6.Total=(1+2+3+4+5)
7.Total Square FG pornsw smcs,ree a aadmau►
Check Betow
❑ Conservation-Commission Fling
(if applicable)
❑ Old Kings Highway�Historical
Commission approval
(if applicable)
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