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Application for a Permit to Build
Fee must accompany this application
Yaimouth 167 "e/ 19.9a
TO THE BOARD OF SELECTMEN
The undersigned hereby applies,/ for a permit to build, according to the following specifications:
L Name of Owner /rrebnQ4 /WO 5 See a NN ate Address a y /3�i c �e"--)00 I..)
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2. Name of Architect (if any) NO rt1-e
3. Name of Builder 2? ',E) ANO A--/atcA) / -577 AD
4. Precinct No. 3 Lot No. 47 Plan: Name or No.A.M.77-W 69
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5: Name of Stree? s3c,Ku30OD bC.
6: Purpose of Building . Our .S/fe 577-PP-'I e 1///0
7. Material X00
8. Estimated cost of building 6�4•. W u op
9. Dwelling g'ic /0 Ont.r'ry
10. Cottage .g
• 11. Heat
12. Basement
13. Garage
14. Store .
15. Shop
16. No. of stories
17. Is there to be a Store in the lower storey _
18. Size of Lot. No. of feet front No. of feet rear No: of feet deep
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19. Size of building. No. of feet front 0 No. of feet side No. of feet rear v
20. Distance from nearest building: Front ft.; side ft.; side ft.; rear
21. Distance back front line or street , from rear lot line , side line
Show by diagram the location of propsed building with relation to dista es from adjoining , on verse side.
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Address... ....w.. l,( "`
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Rear of Lot
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1 O 0 1
46
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03 b 7
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m•ressm,es es
Frontage of Lot
Street Name •
PLOT PLAN
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PLICANT A - •r' ' ' BLDG PERMIT NO
5 _ .
CATION +OF 'PROPERTY: • •' • -' ' •• • _- '• •'-' DATE.FILED: ' • ' - • -
THE FOLLOWING CHECK-OFF SHEET IS-DESIGNED TO CLARIFY THE 'PROCEDURES AN. •INDIVIDUAL. - •:-.:•
ST FOLLOW IN' ORDER TO OBTAIN. A PERMIT TO BUILD OR ALTER A •BUILDING. •-THE BUILDING:. i--_ ••a-"�..
PARTMENT WILL CHECK ON ;THE: FOLLOWING:, (A); CONSERVANCY 'DISTRICTS- (B):-i. HISTORICAL. : r=_;`•: •
STRICTS • CC) 'FLOOD PLAINS-\ZONING,, AND WILL BE_ RESPONSIBLE FOR ASSISTING THE= I' .:
PLICANF THROUGH•THE FOLLOWING AGENCIES:;c $C-4:::::-..t‘ -.••'= • -122.'•.I •" '••`'' •y
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• RESIDENTIAL BUILDING A4~' - •i.
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A) . CHECK WITH THE HEALTH DEPARTMEtff IN REFERENCE TO SEPTIC SYSTEMS FOR SEWAGE - -
- DISPOSAL.' -t •' - -+�L -;-..:c :r . . •.- _ .....,,;:•`;:;;.. ... ..
B) . CHECK WITH. CONSERVATION COMMITTEE IF THE' LOT BORDERS ON ANY TYPE. OF•WETLANDS.- :t.'
EXAMPLES:. STREAMS, PONDS, .RIVERS,:OCEAN, BAY, BOGS, MARSH,: ETC: •;:-_--,;•;--- _• '-':_••
C) CHECK-WITH PLANNING BOARD'FDR•LOT_RELEASE- =;_ v`-=='y - ' �-
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'COMMERCIAL BUILDING: )- :...,r7-.2E;r _= +r" - '.Y_; .:; : - 7.-:7:-:.::c-. `•"'
- 7%c. `'-* --i'::._ i-. -.Y :' --:'.J r•::s`• �+-�•: - _-"i'"r-- :• _ Sq: • -.a,.•t'♦.I`+i_:--7•---:��-
_A) •" ENGINEERING DEPARTMENT-FOR-PARKING."ANO DRAINAGE REQUIREMENTS,• TOPCC•zzPHY SITE , i
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- PLAN REVIEW.- _.z:,:.•:;;. { -__• ; : s'_ _ 'C --- It
•B)„ CONSERVATION COMMITTEE-IF LOT BORDERS_ANY TYPE OF WETLANDS. . - - _
C) PLANNING BOARD-TO 'SEE ,•IF LOT- COMPLIES WITH ZONING BY-LAWS. -
O) BOARD OF. HEALTF'.-FDR SEWAGE DISPOSAL REQUIREMENTS, HEALTH RELATED ACTIVITIES.
EXAMPLES: ' SAUNA BATHS, SWIMMING POOLS,. RESTAURANTS, ETC. : _ • -
T) FIRE DEPARTMENT-FOR" PROPERTY PROTECTION, PERSONAL SAFETY, •(SPRINKLERS, SMOKE
DETECTORS). r _ : • • -
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(WED BY: - - - _ -�_= --= ' - tea. -= ____ _=_-_�_.,�a
ENGINEERING •DEPARTMENT:.--.......1.,...c_-_.,;:c...17:-.r..-C.--r.::::-
` AYES tIDOES NOT+APPLY_SIGNATURE: stri s`•- �-z DATE •'
CONSERVAT3ON 'COMMITTEE:"..YESi.."-•*.DOES NOT A-PPLY•"SIGNATURE =ALA; -'+- = DATE 21/J -
PLANNING -BOAR!): :••. ▪ '-YES =. DOES. NOT APPLY• "•SIGNATURE_-`'-' :----Z-r,...:' -_="_•• : DATE-:---- • -
BOARD OF HEALTH: _YES -- DOES NOT APPLY.'_SIGNATURE r • =•: a. DATE' t
FIRE DEPARTMENT:, - .. . • - • YES DOES, NOT APPLY_SIGNATURE - ` • • - DATE-3 = . la _'
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