HomeMy WebLinkAboutBLD-19-2747 . • bi.it ///7/t
ONE & TWO FAMILY ONLY-BUILDING PERMIT
Town of Yarmouth Building Department a
1146 Route 28, South Yarmouth,MA 02664 4492 �'
508-398-2231 ext. 1261 Fax 508-398-0836 �Rl!
Massachusetts State Building Code,780 CMR
Building Permit Application To Construct,Repair, Renovate Or Demolish
a One-or Two-Family DwellingRE..0 E
- - This Section For Official Use � d
Building Permit Number W .Date Applie •. t.11r, ref it id,
• 1 , sCIKS .. Jed, " /,,,,Al BUILDING nzim1-
Building Official(Print Name) Sigrat m .: . ,P"
.SECTION 1:Slit INFORMATION. • •
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
a2 cruiser lone otaii 3g rote y
1.1 a Is this an accepted street?yes ✓ no • Map Num er Parcel Number
13 Zoning Information: 1.4 Property Dimensions: 1
//i/29 103
Zoning District Proposed Use Lot Area(s4 ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yazd
Required Provided Required Provided Required Provided
30 IS as. ,2O N),
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public a. Private❑ Zone: _ Outside Flood 7,pae? Nlunicipal 0 On site disposal system Jd/
Check if yesff
• . 'SECTION 21 PROPERTY OWNERSHIP" '
2.1 Owner'of Record:
'TAritRS HorVA , New /We'd, CT o(,S//22o(p
Name(Print) City,State,ZIP
142 Cola songzo;-'+3s 1'172, Tions. hoe-s,4 ey4Le. 5pd
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) • '
New Construction 0 I Existing Building 0 Owner-Occupied 0 Repairs(s) 0 f Alteration(s) 1A Addition 0
Demolition 0 I Accessory Bldg.0 Number of Units_ I Other 0 Specify: '
Brief Description of Proposed Work2: (U4- nCato I0,{.re11 r$ew pttc4r4- bullekeac(
. •
SECTION 4 ESTIMATED CONSTRVCTION COSTS
Item Estimated Costs:
(Labor and Materials) 43f[Ic1aI iTse Only
1.Building $ :1::Bmldng Permit Fee:- 50 .. Indicate how fee.is determined:
2.Electrical g " *Standard City/TownApphcation ee ..• _'.:":: ..' ':'':• :
D.TotalProject Cost'(Item 6)x multiplierx... - : ' : •• -
3.Plumbing $
2, —<.
4.MechanicalList. '
(HVAC) $ ... ., . .;; :. :.
5.Mechanical (Fire = .
Suppression) Total AIl Fes:$
ClieckNd: • . Check Amount: Cash.Amount
6.Total Project Cost: S a sin p Paid m'Full 11Od standing Balaiice Due:_/Sr—
- . . SECTION 5:,CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) _
^ , � 60655-3 3
1.. License Number iratior
Name of CSL Holder
List CSL Type(see below) GZ
No.a dY S� Type . . Descriptic
U Unrestricted(Buildings uF
- y_1/4ut..s-- wed C'7 Cr 6 /f R Restricted 1&2 Family Dv
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
1st 3C.44 - C / 57 SF Solid Fuel Burring Applin
cbS 59gk937 Cck\AdwLao eC ee4 scutl I Insulation
Telephone Email address D Demolition
5.2 Registered Home.Improvement Contractor(BIC)
C—t".c %-Ue r^ HIC Registration Number
BIC Com�cyyN�r HIC Registrant Name
`�� �
No. and Street c�
S<
/ G,,iA ozlpi P8 $li)7 Email adare
City/Town, State,ZIP Telephone
SECTION 6:WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.t.152.
Workers Compensation Insurance affidavit must be completed and submitted with this application. Fai'
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes iti No o
• SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner of the subject property, hereby authorize
to act on my behalf,in all matters relative to work authorized by this building permit application.
S 1/'oroA-tA 100,E
Print Owner's Name(Electronic Signature) D
• • SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the infon
contained in this application is true and accurate to the best of my knowledge and understanding.
f
Print Owner's or Auth rized Agent's Name(Electronic Signature) —�'�3t�`D
NOTES: .-
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregit
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the a
program or guaranty fund under M.G.L. c. 142L Other important information on the HIC Program
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mas
2. When substantial work is planned,provide the information below:
Tntal flnnr arna (en fi 1 /:....1...7:............... a..:..i...a L..asmsra.ia.:a 2
��_ .- VUrvcutttt a.J tr41SJSlSG✓LUUSetLS
". h.� �i 't Department of Industrial Accidents
=eCrI Congress Street,Suite 100 •
•r'
-,;%.111,==f
Boston,MA 02114-2017
%+.;,.a' • www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information ,� Please Print Legibly
• Name (Business/Organization/Individual):_Q'/� e-c"i— b .t•-ti
Address: I Lit" c , yr.-T-144)-k 1 O z-6 j
City/State/Zip: Phone#: Sd 9 392' -•
8137
Are you an employer?Check the appropriate box:
-
Type of project(required):
L❑I am a employer with employees(full and/or part-time).*
7. ❑New construction
20 I am a sole proprietor or partnership and have no employees working for me in
any capacity.[No workers'comp.insurance required.] 8• ❑Remodeling
3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t S. ❑Demolition
4.0 I am a homeowner and will be hiring contactor to conduct all work on my property. I will 100 Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electricsl repairs or additions
proprietors with no employees.
5. '1 am a general contractor and I have hired the sub-contractors listed on the attached sheet 17'❑Plumbing repairs or additions
These sub-contractors have employes and have workers'comp.insurance.[ 13.0 Roof repairs
6.0 We area corporation and its officersw have exercised theright of exemption per MGL C. 14.®Other-T�JT4I (Wnlc/ be
152,§1(4),and we have no employees.[No workers'comp.insurance required.] go 11? ,,,(/
""�
*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 at the sub-contractors and ante whether or not those entities have
employes. 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: i Q,Qm Tug' 06
Policy#or Self-ins.Lic.#: (A] lU C 7 ' 2 Expiration Date:'' II C¢- 0-20/
Job Site Address: ea02 Cf f/Ye' [a, City/State/Zip:A), b¢f'l
Attach a copy of the workers' compensation policy declaration page(showing the policy numbetand expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
Ido hereby certify r der the pains and penalties of perjury that the information provided above is true and correct
Signature: 5 / l Date: ,/O-21y-/g
Phone#: 'c505tagq yq/o
Official use only. Do not write in this area,to be completed by city or town officiaL
•
City or Town: Permit/License# .
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: • Phone At:
• • oE'Y TOWN OF YARMOUTH
-- BUILDING DEPARTMENT
-• o ff' 53 1146 Route 28,South Yarmouth,MA 02664
Ssa, .Ye.? 508-398-2231 ext. 1261 Fax 508-398-0836
•
BUILDING DEPARTMENT
DEMOLITION DEBRIS DISPOSAL AFFIDAVIT
Pursuant to M.G.L. Chapter 40, Section 54 and 780 CMR, Chapter 1, Section 1113,
1 hereby certify that� � the debris resulting from the proposed work/demolition to be
conducted at t/ /S2/ /,iicc .
Work Address
Is to be disposed of at the following location: SI 7-615CCv
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, Section 150A.
/6—e -6/
Signature of Application Date
Permit No.
•
J--- 1 YARDLAN-01 TVANRYSWOOD
ACORO' CERTIFICATE OF LIABILITY INSURANCE DATE 09/13/2018Y)
`� 09/1312018
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the poilcy(les)must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on
this certificate does not confer rights to the certificate holder In lieu of such endorsement(s).
PRODUCER CONTACT
E'
Rogers&Gray Insurance Agency,Inc. HNIT hi): MG,
4t
No 877 816-2156
South De
Dennis,is,MA 02660 hss:mail@rogersgray.com ( )( )
INSURER(S)AFFORDING COVERAGE NAIC# .
INSURER A:Arbella Protection Insurance Company,Inc. 41360
INSURED INSURER B:Wesco Insurance Company 25011
Yardscape Landscape&irrigation Inc& INSURER C
Bella Pools
327 Whites Path Road INSURER D:
South Yarmouth,MA 02664 INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFF POLICY EXP LIMITS
I TR INSR WYD IMMIDDIYYYYI (MM,DDIYYYYI
A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
CLAIMS-MADE �X OCCURDAMAGETORENTED
8500046547 03/18/2018 03/18/2019 pREMrsES tea occurrence) $ - 100,000
MED EXP(Any one person) $ 5,000
PERSONAL SADV INJURY $ 1.000.000
GEN.AGGREGATELIMIT
Li LIIMIIT APPLIESPER: GENERAL AGGREGATE $ 2,000,000
POLICY JECT LOC PRODUCTS•COMP/OPAGG $ 2,000,000
OTHER: $
A AUTOMOBILE LIABILITY (Fa accAdeD31NGLE LIMIT ntl $ 1,000,000
ANY AUTO _ 1020015747 03/18/2018 03/18/2019 BODILY INJURY(Perperson) $ —
OWNEDUpTE� NLY X AUTTLOSSW�NEEDp PBPOORDILY INJURYpp (Per accident) $ _
X AUTOS ONLY X AUTOS ONLY (Per accdent7AMAGE S
S
A X UMBRELLA LIAR — OCCUR EACH OCCURRENCE 1,000,000
EXCESS LIAR X CLAIMS-MADE 4600046549 0311812018' 03/18/2019 AGGREGATE 31,000,000
DED X RETENTIONS 10,000 S
B WORKERS EMPOYERS COMPENSATION PER
YIN STATUTE FR
ANYApNpPROPRIETORW/PARTNER'EXECUTNE WWC3352862 06107/2078 06107/2079 E.L.EACH ACCIDENT $ 1,000,000
(Alandatoory In BER EXCLUDED? I NIA E.L DISEASE•EA EMPLOYEES 1,000,000
If yes,describe uunnder 1,000,000
DESRIPTION OF OPERATIONS below E.L.DISEASE•POLICY LIMIT $
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space I.required)
Landscape&Gardening Contractor
Workers Comp Information-Officers Included
RE:22 Cruiser Lane West Yarmouth,MA 02673
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Town Of Yarmouth THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Building Dept ACCORDANCE WITH THE POLICY PROVISIONS.
1146 Route 28
South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE
` ew-----------
ACORD 25(2016/03) 01988.2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
•
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®r ' Massachusetts Department of Public Safety
Board of Building Regulations and_Standartfi.-
•
License: CSFA-060653
Construction Supervisor 1 &2 ,
Family .
9 MAY ES AEHOLMAN tie
SOUTH YARMOUTH MA 02994
C
rc(60 lit/s,-`" Expiration:
Commissioner 01@02019
I
"-, "-+„ "` '� Orrooxa�rr4ealdp�( faAtltdetl`i
%'wry„ •r.. _. . +1
{I[ 5 " ;_ � r Oraapst Consui:cr A/ri6ai:erntnzs�Reyii�tq�,1
+ HOME IMPROVEMENT CONTRACTOR I
-..,..:•-•, _ ,""TYPE:IrWlvitlu.y - t
1 18$43+5
I CHARLES HOLMAH` �'" , -- I.454"'. - QZO7 0t9
, 5 ., I,
;` • CHARLES HOLMAt r ,tii
9May Lane
r'` S.Yaml0u0ir MA 02864_<- 3
Undersecretary
setqfrs TOWN OF YARMOUTH
° HEALTH DEPARTMENT
.
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PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET
To be completed by Applicant:
Building Site Location: 22- 5 c L,J 1 n /
Proposed Improvement: .-{-..cg-f cbt I I>c - c 'as t- ocu t(.ci�( �"Stt,�-�t //fir rye.r..--
Ue Tel. No.: Sd$ 39Y 8?3)
Address: ?Med ,7 S•`c .�- Date Filed: /(-2-/S
**/fyou would like e-mail notification of sign off please provide e-mail address:
Owner Name: I C fr 4eA A ce
Owner Address: I `^( 7. C .tJS'jzr tq/ Cr Owner Tel. No.2,03 kis/?77
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 existing and proposed)-
Note:Floor plans not required for decks,sheds, windows, roofing;
(3.) If necessary, Title 5 application signed by licensed installer
with fee.
REVIEWED BY: / DATE: ///a// a
PLEASE NOTE
COMMENTS/CONDITIONS:
04 Y`�R TOWN OF YARMOUTH
% WATER DEPARTMENT
ian 99 Buck Island Road
� �: West Yarmouth, MA 02673
Telephone: (508) 771-7921 • Fax: (508) 771-7998
' • BUILDING PERMIT APPLICATION
DEPARTMENTAL SIGN OFF TRANSMITTAL SHEET
I,
Bldg. Site Location _ter, t5 c..4- LAD i
Proposed Improvement: � 'cC -
,,l1 +-taz
cn _ 1j,(4_
Applicant: Orr U.a ..r _k.±-=_ ..r-i_
Address ?fry
/ /-,,, Sy eary___ Tel. # CZB 348 -gc 7Date Filed: / f- 2.,_-_, Ig_
RESIDENTIAL AND / OR COMMERCIAL BUILDING
Water Department: Determines Compliance of Water Availability and or Existing Location
Engineering Department: Determines Compliance for Parking and Drainage
-"---.t!::- .7----±',..- C mp! d . . :::-..)-:1%,'
Wetlands, Streams,Ponds, Rivers, Ocean, Bogs, Bays;Marshland, Etc...
Health Department: Determines Compliance to State and Town Regulations, i.e., Requirements
for Septage Disposal and other Public Health Activities
F.re Depart-rt. • Determines Compliance to State and Tern Pequiremerts for Persona'
Safety, Property Protection;, i.e. Smoke Detectors, Sprinkler Systems, Etc
y ,' _a• . — Da:c
PLEASE NOTE:
COMMENTS:
7 - - /1Z / -
Reviewed by: ater Division ate
a
• Rem TEST HOLE LOG
stc e.S Is
1' DATE: AAe• Zv /998
/ SOIL EVALUATOR: -0•.Ll�so•J Esc
WITNESS:. Cic.0 ‘./r--,0.0
st
PERC RATE: a?--WA-..///- c/e/
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Io 23 e, D
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et DoT ZI 3Z1I , I /0 4.51/r7 I313 /27 Tho
Z� - �`---� `�„•�' (� �2o No wA>e/L c AJcovaT4,eC.
�° I 5.t:2. - "� L\�
\ RECEIVED
, � s4I NOV 022018 f 0
/°,i• 11 $ I / peopeksQ3P f At)cKc.«
I u _ Dwc<.c,Ady- Q H�FALTH DEPT. ESIGN DATA
I DAILY FLOW:(4-)BDRMS.z 110 GPD=� GPD
c I20 - #/ I di /I.t) SEPTIC TANK:4-40GPD t200%= ego- GPD
M/ c USE: /So a GALLON PRECAST SEPTIC TANK
�- JL \ LEACHING FACILITY:
�- pM1� AZ -..--N,
� ( 1USE:a3) SxS.S�y�O �os��k3�zcs
21 i {O.O Ol \ CAPACITY: f
M _ ?J$�` SIDEWALL: 73 x' Z.x 0.7¢ 137 6,
BOTTOM:. /Sr/?RSx o,7f-..32Z•3
i N \-----z( TOTAL:. 469 ,94r42
N az.
7,5II°�,Alrl � . --- .
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DANIEL E
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NOTES:
1. ALL PIPE TO BE 4”DIA.SCII 40 PVC. \ - St-22-O 1 g
1 2. PIPE TO BE LAID LEVEL FOR 2'OUT OF DISTRIBUTION \\\\�a''G`,�♦♦!!I -
(. BOX. r
3. RAISE ALL APPLICABLE MANHOLE COVERS TO WITHIN - QQ
6"OF FINISH GRADE. - � -iS��V
4. SEPTIC SYSTEM IS NOT DESIGNED FOR THE USE OF A -
GARBAGE DISPOSAL,
S. SEPTIC TANK AND DISTRIBUTION BOX TO BE INSTALLED
ON A 6"LAYER OF STONE.
6. INSTALL GAS BAFFLE IN OUTLET TEE. - - PLAYER OF UV PEASTONE OVER
EP.I Pr WASHED STON E,ALL
AROUND
I
TOP OF FOUND. IIZ�,
®EL ZS. o / lIr u• '�' e
z z.0/ I ` 3��/L hb 'rq\ �a'5.:4I /y EEl
p . co
-101
S Z/ SSc. e/o
2�7
km
SEPTIC SYSTEM PROFILE I.
, ,, iii
I . `
SITE -, SEWAGE PLAN GENERAL NOTES
17.;;T„..);„: tfi FOR 1. CONTRACTOR TO BE RESPONSIBLE FOR THE LOCATION
i OF ALL UTILITIES,ABOVE AND UNDERGROUND,PRIOR
k?",:::.
r` "' co T' z_7,-/ pg 2 Z UZU/3<aC' ,C TO ANY EXCAVATION OR CONSTRUCTION.
Ii IJ W )/q e,�o(.3771
�r
(�//7� ��i . 2. SEPTIC SYSTEM TO BE INSTALLED IN COMPLIANCE WITH
PREPARED FOR 310 CMR 15.o01 TrTLEY.
. `. 3.THIS PLAN IS NOT TO BE USED FOR PROPERTY LINE
" 7ax-i A)0 uJ</Z.5 . DETERMINATION.
C
4. ALL DISTURBED AREAS TO LOAMED AND SEEDED.
a .�. DATE:r .4-ire/�' /S /5/13 SCALE: / _ Za
:i',.„1,?. . . E1 A , 13, lisle s CONTRACTOR TO PROVIDE 24 HOUR NOTICE FOR ANY
t<,
REQUIRED INSPECTIONS.
r* ,,``
4 1 _j , IID IG C1 Ii�; 11 Vii 11, 0
"4 : ; Y AUG 1 7 1996 ,
it Y 41t asiaEasz,t.._:�,p.x�CcnnrA.TT_C HEAL FDEPT: ' , t
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I r.',
•
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G/ ,
g�ti��
No�' 0.
)10 P.sc moo.
Irl,
0, . 6
LOT 24 ' 4,0
10,706.2 th S.F. N� QR02°OV
�a
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RODIN % .;t.
:1� WILLIAM N;
WILCOX
A.
°'� No.31340 /gr i'
Pte' „FG/STEL tel
S�ONAt.LA7c•-
TO THE BEST OF MY INFORMATION, "PROPOSED" PLOT PLAN
KNOWLEDGE, AND BELIEF THE WEST YARMOUTH, MASS.
STRUCTURES' SHOWN ON THIS PLAN ` LOT 24; PL:BIC 173/3" ' " ' '
HAS BEEN LOCATED ON THE GROUND DATE 10/1/18 SCALE 1" = 20'
AS INDICATED. .
JOB 8100-00 CLIENT BELLA POOLS
0/1/18 ;- - / !✓G/ /- SWEETSER ENGINEERING
203 SETUCKET ROAD
DATE PROFESSIONAL LAND SURVEYOR PO BOX 713 SOUTH DENNIS, MA 02660
OFF. 508-385-6900 FAX. 508-385-6991
C: 1 S8 1 PROJ 18100-00 I dwg 18100-CPP.DWG 0 2018 SWEETSER ENGINEERING