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4ft-T ° t Application for a Permit to Build No. 1/4-5"2-D
UPON FINAL APPROVAL frzgigjO MAP I b( LOT E- C
FEE MUST ACCOMPANY THIS APPLICATION. DATEOUC ?At 9 70
The undersigned hereby applies for a permit to build , gig_ 90
according to the following specifications_ I L
1. Name of property owner Trn 4-k,0a_l- Te1136254 1U
Address zo 5vrnr.a St` 1r►2M3u+-1-.
2.Name of Architect(if any) Tel.
3. Name of builder___10 kr of 5LfFnnckj _AddresstPo 130X y a7 CGrzee} Hitt S aJ
4. License No. 0504 Pc) Tel. 3'-111 `3 /SS
5. Name of Mason Address
6. License No. Tel.`s
7. Construction address YC Su M GK. 5 4 /tam:3✓'L An k
Flood District
8. Date of subdivision Approval plain zone Zone
9. Private dwelling l% Estimated Cost DO NOT WRITE IN THIS SPACE
10. Multi family 0 4300 d .O v
�fiPLA�,,u6
Type of room No.
11. Commercial 0 enTr-D gi/Gcs 4 Kitchen
12. Other 0 $'/{pe/tY6 fXr 77'o Dining Rm.
13. No. of stories a Tfiter–�S Living Rm.
Bed Rm.
14. Foundation — Full 0 Half 0 Crawp4 Slab ❑, jir Bath
15. Materials — Wood.® Cement27 Other 0 O`-J • a-0 Deck
16. Type of heat — Oil ® Gas 0 Electric 0 Other 0 Closed porch
Family Rm.
17. Garage — 1 0 2A Sun room
18. Swimming pool - Size Garage
19. Storage shed — Size 7x 1 0 Shed
20. Stove — Wood 0 Coal 0 Alterations (✓
21. Size of lot: No. of feet front No. of feet rear No. of feet deep
22. Size of building: No. of feet front ay No.of feet side AZ6 IV No.of feet rear Zie
23. Distance from nearest building: Front_10 ° Ft. side 40 Ft. side _LOS_J Rear
24. Distance back from line or street ~'S 0 From rear lot line ) 10 0 Side line Ft-lb 3 0
LOT RELEASED BY Signature ' I� 6'IQ
PLANNING BOARDAddress 71S Sax 4.2 7 ERc.,,7L g7 Cf ft)
Date it Inn . o? AhG
TOWN OF YARMOUTH
BUILDING DEPARTMENT
CONSTRUCTION SUPERVISOR FORM
PLEASE PRINT: /
JOB LOCATION: 26 St/rn c,t 5 14LFi °i
NUMBERSTREET VILLAGE
OWNER OF PROPERTY: Zinn Ka tA..-C 11'
CONSTRUCTION SUPERVISOR: )��-R f' SI. RG'nFl t{'c 050 q gO 3141-3)C?
AME // 'LICENS-E� NO. PHONE NO.
ADDRESS: ? t3OX 'Ia) 2t/eo mR Gr jc+ IT+,LE-5 1`p C' +ZQe,O
LICENSED DESIGNEE:
(IF OTHER THAN SUPERVISOR) NAME LICENSE NO.
2.15 RESPONSIBILITY OF EACH LICENSE HOLDER:
2.15.1 THE LICENSE HOLDER SHALL BE FULLY AND COMPLETELY RESPONSIBLE FOR ALL WORK FOR WHICH HE
IS SUPERVISING. HE SHALL BE RESPONSIBLE FOR SEEING THAT ALL WORK IS DONE PURSUANT TO THE STATE
BUILDING CODE AND THE DRAWINGS AS APPROVED BY THE BUILDING OFFICIAL
2.15.2 THE LICENSE HOLDER SHALL BE RESPONSIBLE TO SUPERVISE THE CONSTRUCTION, RECONSTRUCTION,
ALTERATION, REPAIR, REMOVAL OR DEMOLITION INVOLVING THE STRUCTURAL ELEMENTS OF BUILDING
AND STRUCTURES ONLY PURSUANT TO THE STATE BUILDING CODE AND ALL OTHER APPLICABLE LAWS OF THE
COMMONWEALTH, EVEN THOUGH HE, THE LICENSE HOLDER, IS NOT THE PERMIT HOLDER BUT ONLY A SUB-
CONTRACTOR OR CONTRACTOR TO THE PERMIT HOLDER.
2.15.3 THE LICENSE HOLDER SHALL IMMEDIATELY NOTIFY THE BUILDING OFFICIAL IN WRITING OF THE
DISCOVERY OF ANY VIOLATIONS WHICH ARE COVERED BY THE BUILDING PERMIT.
2.15.4 ANY LICENSEE WHO SHALL WILLFULLY VIOLATE SUBSECTIONS 2.15.1, 2.15.2 OR 2.15.3 OR ANY
OTHER SECTION OF THESE RULES AND REGULATIONS AND ANY PROCEDURES, AS AMENDED, SHALL BE SUBJECT
TO REVOCATION OR SUSPENSION OF LICENSE BY THE BOARD.
2.16. ALL BUILDING PERMIT APPLICATIONS SHALL CONTAIN THE NAME, SIGNATURE AND LICENSE NUMBER OF
THE CONSTRUCTION SUPERVISOR WHO IS TO SUPERVISE THOSE PERSONS ENGAGED IN CONSTRUCTION, RECON-
STRUCTION, ALTERATION, REPAIR, REMOVAL OF DEMOLITION AS REGULATED_ BY SECTION 109.1.1 OF THE
CODE AND THESE RULES AND REGULATIONS. IN THE EVENT THAT SUCH LICENSEE IS NO LONGER SUPERVISING
SAID PERSONS, THE WORK SHALL IMMEDIATELY CEASE UNTIL A SUCCESSOR LICENSE HOLDER IS SUBSTITUTED
ON THE RECORDS OF THE BUILDING DEPARTMENT.
I HAVE READ AND UNDERSTAND MY RESPONSIBILITIES UNDER THE RULES AND REGULATIONS FOR LICENSING CON-
STRUCTION SUPERVISORS IN ACCORDANCE WITH SECTION 109.1.1 OF THE STATE BUILDING CODE. I UNDERSTAND
THE CONSTRUCTION INSPECTION PROCEDURES AND THE SPECIFIC INSPECTION AS CALLED FOR BY THE BUILDING
OFFICIAL. r
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SIGNATURE: -/4- s
BUILDING OFFICIAL APPROVAL: