HomeMy WebLinkAboutBld-20-001080 ,YRR 1 Office Use Only
" O Permit#
30
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4` .,`.... °"�c )Permit expires 180 days from
B(-lir ZO 1(2. 01
{issue date
EXPRESS BUILDING PERMIT APPLICATIOIN R E C E I V
TOWN OF YARMOUTH _
1 F
Yarmouth Building Department j AUG 26 200h
1146Route28 j
South Yarmouth, MA 02664 L ' R T M E N r i
(508) 398-2231 E t. 1261 I
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CONSTRUCTION ADDRESS: I q 0 ozos S S W` ,Q(N
ASSESSOR'S INFORMATION:
�/� Map: �i1 ( Parcel:
OWNER: 4 ►' \C?c— �, •1).� r`l)'��{' 1 -3.-. —k ' S.(�6(/ln , 0& 3 e-( (OS
NAME j PRESENT ADDRESS TEL. #
CONTRACTOR: d(
NAME MAILING ADDRESS ie.#
'NcResidential ❑Commercial Est.Cost of Construction$ 4711 Sb 0'
Home Improvement Contractor Lic.# Construction Supervisor Lic.#
Workman's Compensation Insurance: (check one)
1i I am the homeowner ❑ I am the sole proprietor 0 I have Worker's Compensation Insurance
Insurance Company Name: Worker's Comp.Policy#
WORK TO BE PERFORMED
Tent Duration (Fire Retardant Certificate attached?) Wood Stove
Siding: #of Squares C Replacement windows: # Replacement doors: #
Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation
WO Old Kings Highway/Historic Dist. (A)Replacing like for like Pool fencing
*The debris will be disposed of at: tS pa(J�i,Q, c 42C CjI''l
Location of Facility
I declare under penalties of perjury that th nts herein contained are true and correct to the best of my knowledge and belief. I understand that any false answer(s)
will be just cause for denial or revoc of m i ense and for prosecution under M.G.L.Ch.268,Section 1.
< /41Applicant's Signature: Date:
Owners Signature(or attachment) Date:
Approved By: 1 ,L Date: % - ) '
Building Official(or designee) ADDRESS:
Zoning District:
Historical District: ❑ Yes 0 No Flood Plain Zone: ❑ Yes ❑ No
Water Resource Protection District: Within 100 ft. of Wetlands:
0 Yes 0 No 0 Yes ❑ No