HomeMy WebLinkAboutBLD-19-4018 Elliott, Ken
From: Cipro, Linda
Sent Tuesday,January 15, 2019 10:21 AM
To: Hall, Lee; Elliott, Ken; Inkley, Brad; Murphy, Bruce; Huck, Kevin; Sawyer,Jon;Simonian,
Philip; Smith, Scott
Subject: 196 Higgins Crowell Rd
Good Morning,
The Building Department is scheduled to conduct a final for occupancy inspection at 196 Higgins Crowell Rd—dental
office—on Friday 1/18/19 and would like for you to attend. The contact person is Dina Dexter and she can be reached
at 508-685-6048. Please notify me regarding your inspection results.
Thank you,
Linda
ttel ill it
1
•
r
..01-tiit, BUILDING PERMIT APPLICATION
• . �4 r APPUCATION TO CONSTRUCT,REPAIR, RENOVATE, CHANGE THE USE, OCCUPANCY OF,
i€; JC OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING.
O Town of Yarmouth Building Department
F�`,+..%^0 : II-15Route 28 • Yarmouth, MA 025644492 I R E C L, f t!
t
_
Tel: 508.398.2231 ext. 1261 Fax 508-398-0836r �^ -I
I l — 4-•1
Office Use Only ,� Planning Board Information Assessors Department Information: �AN t C:1 t J
PermitN D-(9-Oa7�af Plan Type kr
,-i_il-m—._f_-- ---- _1
Permit Fee $ �1 1/
Endorsement Date kr A T.: I/ - _
VVRecording Date New
Deposit Recd. $ p Date I/11 elan No. 1.4 Property Dimensions:
Net Due ./ Other Lot Area(at) Frontage(It) Lot Coverage
This Section for Office Use Only
Building Permit Number: Date Issu
Signature: • / -PI -/y CeRificate of Occupancy
Building Official Date is M Is not - required
Section 1 - Site Information
1.1 Property Addresst 1.2 Zoning Information:
1q4 14199ins CrowedI Rot r
/ Loes # Yarm o of h) m o a& 13 Zoning District Proposed Use
✓ 1.3 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.4 Water Supply(MOS.e.40.5 54) 1.5 Flood Zone Informatics's Comment -‘'
Public Private Zone: BFE;
Section 2- Property Ownership/Authorized Agent
2.1 Owner of Record:
TcI-fevson S be*fr, tel(0 NI-93tits C►v ( l Ra
Name(print) Mailing Address:
Sign?ta Telephone Telephone
Email Address:
2.2Authoriz Agent: bine bvettrx dirutrock. aD 0.o►• cote)
Hamra(print) Mailing Address:
(-04-00A,t�c.tit 508 In 83 670 Ye ,
signature Telephone Fax
Email Address: I
Section 3 - Construction Services
3.1 Licensed Construction Supervisor Not Applicable U
License Number
Address
• Expiration Date
Signature Telephone Email Address:
Y
w
3.2 Registered Home Improvement Contractor. •
Company Name Not Applicable ❑ '
Registration Number •
Address
Expiration Date
Signature Telephone
Section 4-Workers'Compensation Insurance Affidavit(M.G.I_c.152 S 25C(6)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure
to provide this affidavit will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes No
Section 5- Professional Design and Construction Services-for Buildings and Structures Subject
to Construction Control Pursuant to 780 CMR 116(containing more than 35,000 c.f. of enclosed space)
Section 5.1 Registered Architect
Not Applicable U
Hams(Registrant): Registration Number
Address
Expiration Data
Signature Telephone .
Section 5.2 Registered Professional Engineer(s) •
Area of Responsibility
Hama
Address Registration Number
Signature Telephone Expiration Date
Area ol Responsibility
Hams
Address Registration Number
Signature Telephone Expiration Date
Area of Responsibility
Nama '
Address Registration Number
Signature Telephone Expiration Date
Area olResponsibility
Hams
Address •
Reg strat on Number
Signature Telephone Expiration Date
Section 5.3 General Contractor I `
• Not Applicable U
Company Name
--- ,—.--. _-. _ Person Responsible for Construction
Address
Signature Telephone
, Section 6- Description of Proposed Work(check all applicable)]
' New Construction ❑ (tor multiple family only) No.of Bedrooms (for multiple family only) No.of Bathrooms
• - Existing Bldg. ❑ Repair(s) ❑ Alterations ❑ Addition ❑
Accessory Bldg. ❑ Type Demolition Other Specify:
Brief Description of Proposed Work:
ben tail Practice
SOIL Prac-fLticntr
Section 7- Use Group and Construction Type
Building Use Group(Check as appficapable) Construction Type
• A ASSEMBLY ❑ A-1 ❑ A-2 ❑ A-3 ❑ 1A ❑
— A-4 ❑ A-S ❑ 13 ❑
B BUSINESS ❑ 2A ❑
E EDUCATIONAL ❑ 23 ❑
F FACTORY ❑ F-1 ❑ . F-2 ❑ 2C o
H HIGH HAZARD ❑ 3A ❑
1 INSTITUTIONAL ❑ I.1 9 1-2 ❑ 1-3 ❑ 38 ❑
M MERCHANTILE ❑ 4 ❑
R RESIDENTIAL ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑
S STORAGE ❑ S.1 ❑ 5-2 ❑ se - ❑
U UTILITY ❑ SPECIFY: '
M MIXED USE ❑
SPECIFY:
S SPECIAL USE ❑ SPECIFY:
Complete this section if existing building undergoingrenovations:additions and/or change iri use.
Existing Use Group: Proposed Use Group:
Existing Hazard Index 780 CMR 34 Proposed Hazard Index 780 CMR 34
Section 8 Building Height and Area •
Building Area Existing(if applicable) Proposed
Number of floors or stories
include basement levels
Floor Area per Floor(sf)
Total Area All Floors (sf)
Total Height(ft) •
Section 9-STRUCTURAL PEER REVIEW(780CMR 110 11)
Independent Structural Engineering Structural Peer Review Required Yes No
SECTION 10a OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
Te Hereof) 5 beyter bme Pc , as Owner of the subject property,
7 hereby authorize tce'"c 0/n et.. 10811 f-t✓ to act on '
[/ my behalf, in all matters relative to work authorized by this building permit application.
/ //
Signatur of Owner Date
o .a A .,,.e..
y
i
SECTION 1 Ob OWNER/AUTHORIZED AGENT DECLARATION
I,. , as Owner/Authorized Agent
hereby declare that the statements and information on the forgoing application are true and acurate, to
the best of my knowledge and belief.
Signed under the pains and penalties of perjury.
Ulna Dexty✓ .
Print Name Akita- , &Lt. f / 4, / f9
•
Signature of Owne Date
Section 11 - ESTIMATED CONSTRUCTION COSTS
Item • Estimated Cost(Dollars)to be
completed by permit applicant
1.Building
a Electrical
3.Plumbing/Gas
•
4.Mechanical(HVAC)
1 5.Fire Protection
J &Total-(1.2+3+4.5)
' 7.Total Square Ft.ter new nuns&an)
•
Check Below
❑ Conservation-Commission Filing
(if applicable)
❑ Old Kings Highway&Historical . -
Commission approval
(if applicable) •
• The Commonwealth oJMassachusetls
Department of Industrial Accidents
_ ``=
Office of Investigations
• = —�$__— .600 Washington Street •
• '� - Boston,MA 02111
of
•www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/organizationandividnaly SC Revs o/1 5 &v+-eY bin is P G
Address: 191., 1-41.99,11.5 Cro wt ll RcC
City/State/Zip: L )65+ "/av n'l0 o f h MAPh #3 50 8 7. 3. 1 - to I 0 a
Are you an employer?Check the appropriate box:
I. i am a employer with a FT a PT 4. 0 I am a general contractor and I Type of project(required);
Lr
have hired the sub contractors . 6. ❑New consntrction
employees(fall and/or part-time).;
2.0 I am a sole proprietor or partner- listed on the attached sheet. 7. D Remodeling
ship and have no employees These sub-contractors have 8. 0 Demolition
working for me in any capacity. employees and have workers'
[No workers'comp.insurance comp.insurance.*
9. 0 Building addition
req ired] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3.0 I am a homeowner doing all work officers have exercised their . 11.0 Plumbing repairs or additions
myself [No workers' comil right of exemption per MGL
•
insurance required.]t c. 152, §1(4),and we have no 12.11 ••f repairs
3 a.D I am a homeowner acting as a : employees.[No workers' 13.I Other •
general contractor(refer to 444) comp.insurance required.]
'Any applicant that checks box#1 must also fill out the section below showing their workers'eompeasatio4olicy infomonticm.
t Homeowners who submit this affidavit indicating they aro doing all work and then him outside contractors must submit a new affidavit indicating such
:Contractors that check this box must attached an additional sheet showing the name old=sub-contactors and state whether or not those entities have
employees. If the sub-mnaactoa have employees,they must provide their woken'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 certify under the pains and penalties of perjury that the information provided above is true and correct
•
Signature: ki.At'th. Date: l / } ' l c(
Phone#: 505 (905 60y8
Official use only. Do not write in this area, to be completed by city or(own ofraiaL
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#:
Information and Instructions
Massachvsctu General Laws chapter 152 requuss.all employers to provide workers'compensation for their employees.
Pursuant to this stature,an tnrpign
is defined as"_.every person is the service of another under'any contract of hire,
express or implied,oral or written."
An employe is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
in a omt and including the legal representatives of a deceased employer,or the
ofethe fr tingengaged of ' j erSbi
receiver or tante of m iadiridtal,partnership,:nautical or other legal entity,employing employees. KOsrna the
owner oft dwelling hoax hiving not more than three apartments and who resides therei ,or the occupant of the
dwelling house of another who employs persons to do res nt'T'_v-P,construction or repair work on such dwelling house
or on the grotmds oc building eppurtment thereto shall not because of such employment be deemed to be an employee
MGL chapter 152,§25C(6)also sista that"every stats or foal licensing ageecy shall withhold the lasames or
renewal of a license or permit is operate a business or to construct buildup u the eommornaltt for sn
a s has net produced acceptable evidence of compliance with the Insane*coverage required."Arkrlistinmawho
MGL chapter 152, §25C(7)states"Neither the commonwealth nor may of iter political subdivisions shall '
public of work until acceptable evidence of complianoa with the imam=
cater into any contact tot the performerperformer "
requusmcnts of this chapter have been presented to the c rdractg aurhotity.
•
Applicants • ,
Please 1571 out the workers'con aha affidavit completely,by checking the boxes that apply to your sttuataa and,if
necessary,supply sub-contractor(s)name(s),address(a)and phone umber(*)along with thea certificate(s)of
insmaance. Limited Debility Comp�sm,tes(LLC)ere Limed m
Liability Paashipe(LLP)with no employees other then the
members or pS�,are not required to carry wurken,compensationinsurance. 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
' ACC/dent{ toe confoo atioa of insurance coverage. Ates be tart to sign and data the alZdavl6 The affidavit should
be retuned to the city or town that the:Minden for the past oc license is being requested,net the Department of
Industria!Accidents. Should you have any questions regarding the law or if you am required to obtain a workers'
compensation policy,please call the Departss:d at the number listed below. Self-insured companies should eater their
self-added liana miter on the appeopeiatt lig.
City or Tura Olfel k •
Please be nue that the affidavit is complete and printed legibly. The Department has provided i 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 additioe,an applicant
•
that must submit multiple permiNticense applications in any given year,need only submit one affidavit indicating=rent
policy inhumation(if necessary)and udder"Job Site Address"the applicant should writs"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 fits fns Genre permits or games. A new affidavit mat be filled at each
year.Where a home owner or citizen is obtaining a license oc permit not related to any business or commercial vents
(Le.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit
The Oaks of Investigations would like to thank you in advance for your:cooperation and should you have any questions.
please do not hesitate to give un a tail.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts • ?,
•
Department of Industrial Accidents •
Oath of Investigations
600 Washington Street
Boston,MA 021 ll
Tel. (1617-727-4900 ext 406 or 1-877-MASSAFE. . .
Fax (1617-727-7749
Revised 11-22-06 • wwv,massgov/dia
P
TOWN OF YARMOUTH
' r. e BUILDING DEPARTMENT
' • osets� "£ "y. 1146 Route 28,South Yarmouth,MA 02664
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 111-5,
I hereby certify that the debris resulting from the proposed work/demolition to be
conducted at
Work Address
Is to be disposed of at the following location:
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Chapter 111, Section 150A.
Signature of Application Date
Permit No.
•
•
1 , Workers Compensation And Employers Liability Insurance Policy WC 00 CO 01 A
Carrara N Privltle.la:
t!!irLib Policy Number.
Mutual. nsoarocasuamerwaaeeAllmon), lxwo119)8r Number
aauRaRaa Prior Policy
NCCI Co.No. 1113631
I Workers Compensation and
Employers Liability Insurance Policy
Information Page
ITEM 1:Tee Ierred it Melling Address Agent Melling Address&Meas No.
JEFFERSON S DEXTER DMD PC (855)297.2017
657 MAIN ST' USI INSURANCE SERVICES LLC
WEST YARMOUTH,MA 02673 3 EXECUTIVE PARR DR STE 300 - _
BEDFORD,NH 03110-6990
riiiiii
hdtvldoal_PadaetfllA
X Carysrtlas rare--- _ Filet 061717095 NAICas2l2to
Omer wnglaeas net shows above
ITEM 2 Tee policy petted Is from 05/10/2018 to 05/10/2019 12:01 ern Standard 71me at the Insured's mailing address.
ITEM 3 A.Workers Compessetles lesorenee:Part One of the policy applies to the Workers Compensation Law
of the states listed here: MA
B.Employer Liability Insolence:Part Two of the policy applies to work In each state listed in Item 3.A
The limits of our liability under Part Two are: Bodily Injury by Accident $5N,0N each accident
` Bodily lnury by Disease $500,000 policy limit
Bodily Inury by Disease $500,000 each employee
C.Otter States lasaranee:Part Three of the policy applies to the states,if any,listed here:See RII
Extension of Information Page
B.This pelley includes these endorsements andscheduler See Policy Forms and Endorsements Summary
ITEM 4 The premium for this policy will be determined by our Manuals of Rules,Classifications,Rates and Rating
Plans.All Information required below is subject to verification and change by audit.
Classifications Code Premium Bash•Total Rate per Estimated
lb. Estimated Anneal $100 of Annual
Remuneration Remuneration Premium
See Extension of Information Page(s)
Total Estimated Annual Premium $308.00
Total Surcharges and Assessments $3.00
Mlntmm Premimt $239.00 MA Total Estimated Cost $311.00
If Indicated below,interim adjustments of premiums shall be made.
Deposit Premium $311.00
1 {
Issue Date 03/26/18 Countersigned by:
Ts report a claim,callut
jrd Agent of 1400462•01000
WC 00 00 01 A (WC 30 10 E)
m 1987 National Council on Compensation Insurance, Inc. r
58502349 POLSVCS 290 PCXFPPNO INSURED COPY 000102 PAGE 9 OF 42 •.:i
•
•
MGL AND FIRE
TOWN pp ygRMOUTH
ERRORS
FOR CODE COMPLIANCE,
ceti S OR OMMISSIONS DO NOT RELIEVE
THE APPLICANT FROM TH
V/
DA E: BUILT COMPLIANE NOT
CE.
DATE;
YARMOUTH FIRE PREVENTION INSPECTOR
New Business Transmittal
Project Name: Jefferson S. Dexter DMD PC Address: 196 Higgins Crowell Rd.
Contact Name: Dina Dexter Phone: 508-685-6048
IY N NA Subject Regulation
ES 0
X Building Numbers MGL Chapter 148;sec 59
X Fire Lanes 527 CMR I;22.3
X Extinguishers 527 CMR I; 13.6,Chapter 148;sec 28
X Maintence of any equipment,system relating to 527CMR1 1.1.4
Fire Protection.
X *Hazardous Materials Storage 527 CMR I;60.1
X Emergency Plan Required 527CMR1 10.9.1
X Commercial cooking,Hood systems 527CMR1 50.2.1.1
X Commercial Cooking Hood Systems Cleaning 527CMR1 50.5.4
X *Commercial Cooking Extinguishment System 527CMR1 50.4.3
X *Candles,open flames,and portable cooking 527CMR1 17.3.2,20.1.1.1
X Blocking electrical panel 527CMR1 10.19.5.1
X Blocking exits 527CMR1 14.4.1
Extension cords shall not be used as a 527CMRI 11.1.7.6, 11.1.7.1
X substitute to permanent wiring
X Limit storage heights to 24 inches below 527CMRl
ceiling without sprinklers 18 inches with
X Maintain Aisle width of 36 Inch's(3 Feet) 780CMR 1101.1
X Storage inside/outside Buildings 527 CMR 1; 10.19.4,4.4.3.1.1,19.1.2,34.1.1
X The right to inspect MGL Chapter 148 Sec.4
X *Upholstery 527 CMR 1;20.6.2.5
X *Trash Containers 527 CMR I; 19.1.1, 1.12
X Any Hazard to the Public Chapter 148;sec 28
X *Curtains,Draperies,Blinds 527 CMR I; 12.6.2
Description of planned project/other requirements:
The YFD support the application, subject to applicable submissions, permits
and inspections.
A Permit from YFD is required any time a fire protection system is shut down.
* YFD permit required-depending on occupancy and submittal
Plan Reviewed By: Captain Kevin Huck Date: 11-14-2018
Copy for Applicant C Copy to Building Department I I Copy to Fire Prevention
Entered in Firehouse I—I Final Inspection
°" f TOWN OF YARMOUTH
0, °- HEALTH DEPARTMENT
rattly
PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET
To be completed by Applicant:
Building Site Location: / % Fit 91715 Cro ute /l got Li)e5l- '/arrnougii, MAOde? 3
Proposed Improvement: p /C . (✓fk/ dg tr – / hes-6! / (t,/GS
Applicant: Tec-FCrS 0n S &'L+er hrn b pC Tel. No.: 5031985 &OVc
Address: lqG 1-11991,15 Crowell got WestVarrnu.f at'e��gAoied: I / 7 // q
""lfyou would like e-mail notification of sign off please provide e-mail address:
Owner Name: c'eF-fCYS0n 5 be'tJer hmYIt5 PG
50a (p85—
Owner Address: Ilp L 1 Y Q eL Owner Tel. No.: (a 0'/6
_
`lac m0t,ilnport__.4 nIA.__.o_ (o_TS ...__.._.._.._......_._..._.._.............__.__._�__.._..__.____-
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: ACC&de DATE: /– 7-19
PLEASE NOTE
COMMENTS/CONDITIONS:
f •
Bre 19976 'Ps 150. 443440
a'Ydl06-27-2005 a 0.1 -30p•
•
• (WI)
• DECISION
. 7115JU11 -6 Mt'itr03 ' •
nun WITH TOWN CLERK: June 6,2005 RECEIVED
PETITION N0. #3961 '
•
HEARING DATE: May 26,2005
•PETITIONER: Dr.Edward&Marianne Hutchinson
PROPERTY: 196 Higgins Crowell Road,West Yarmouth •
Assessors Map/Lot:46.62(40/R7), Zoning District:R40 •
MEMBERS PRESENT AND VOTING: David S. Rei
• . Diane Moudouris,Douglas Campbell and Forrest d' Chairman, John Richards, Joseph Samosky,
•
White,alternate.
It appearing that notice of said hearing has been given by sending notice thereof to the petitioner and all
those owners of property deemed by the Board to be affected thereby,and to the public by posting notice
of the hearing and published in The Register,the hearing was opened and held on the date stated above.
'
The petitioner seeks a modification of a prior variance (#1531-1978) by removing a condition which
.i limited the use relief to the original applicant. .
•
The property is located in the R40 zone. The single-family-home-style building was built and has always
• been used as a doctor's office for a.single physician. .me Variance which allowed it restricted the
Variance to the then applicant and owner. That condition was imposed in 1978. The petitioner now
wishes to retire from his practice and transfer the use of the premises under the Variance to a new
• physician. The use of the premises will not change in general use,nor in volume of activity. It will
remain a single physicians,medical office. No changes to the exterior of the building aro proposed,
• although interior remodeling to accommodate the new physician is contemplated.
The Board received no opposition to the proposal,nor is the Boaid aware of any .
• the office use. Itis located on what is now a b past complaints about
Yours,•causing no problems to its surrounding intersection.neighborhood.
.It has been as unobtrusive use ober the
residential neighborhood The Board concurs with the•
petitioner's claim that the condition could not now lawfully be imposed within ause variance of this sort.
The Board finds that the condition,restricting the use of the Variance to the original
-- _ integrally related to any of the Variance criteria on which the Variance was based,aand mayorwas not
be
eliminated without the need to demonstrate new Variance criteria.
•
•• Therefore,a motion was made by Mr.Richards,seconded by Mrs.Moudouris,to allow so much of this
petition as seeks removal of the condition of Variance#1531,1978,by striking from the Variance the
following;'this variance is restricted to the petitioner and should lapse ifthe property is solder he ceases
personally to use iffor a medical doctors office."
•
The members voted unanimously in favor of the motion. The modification is granted,and except as so
. modified the said Variance remains in full force and effect. The petitionerrequested lcaveto withdraw,
without prejudice,the balance of the petition,as the alternate forms of relief are no longer needed. A
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TOWN OF YARMOUTH
REVIEWED FOR BUILDING AND ZONING CODE COMPLI-
ANCE. ERRORS OR OMMISSIONS DO NOT RELIEVE THE
APPLICANT FROM THE RESPONSIBILITY 'AS BUILT
COMPLIANCE.
DATE:I _l4 13 ---C,
Aeof BUILDING OFFICIAL
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Yarmouth Health Department
AdaiGy10 f-7
ame Date / 7/9 ///GUNS C'e ibzc Rl.)