HomeMy WebLinkAboutBld-20-001322 O1'Y`�R 1 Office Use Only s
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*. _0 :�d Permit expires 180 days from ='
i issue date
EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1146 Route 28 060-co
South Yarmouth, MA 02664
(508) 398-2231 Ext.``1261
CONSTRUCTION ADDRESS: t`ri—S a V- J (,10. ��rs Tjeki.
ASSESSOR'S INFORMATION:
Map: 6 V Parcel: 4)'7o
R-TU
oWNE L et yA Rrnok.M-. 5a -3(0 4 -53 ict
NAMEPRESENT ADDRESS TEL. #
CONTRACTOR:
N ME MAILING ADDRESS TEL.# '
❑Residential 0 Commercial Est. Cost of Construction$ A,14--
Home Improvement Contractor Lic.# Construction Supervisor Lic.#
Workman's Compensation Insurance: (check one)
❑ I am the homeowner
0 I am the sole proprietor ❑ I have Worker's Compensation Insurance
Insurance Company Name: LA e_\�'1"'t 5 ,.M N rQ Ad ter's Cor li
'Ohl '''' I"3 I , 1 WORK TO BE PERFORMED
Tent / Duration 3 (Fire Retardant Certificate attached?) I Old Vs ood Stove
01 ad Xao1
Siding: #of Squares Replacement windows:# Replacement doors: #
Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation
Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing
*The debris will be disposed of at: /i A'
Location of Facility
I declare under pen• • .erj , that t.- statem is 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 or denial o,re .catio, ' ense and for prosecution under M.G.L.Ch.268,Section 1.
Applicant's Sipa _.� l'i1 Date: 7'Z Z
Owners Signature(or attachment) Date:
Approved By: / e, e7
pp (- Date:
Build. ff . (or designee) EN DRESS:
Zoning Dis -: • co a �-
Historical District: 0 Yes ❑ 0
Flood Plain Zone: ❑ Yes 0
Water Resource Protec ' li •ict: Within 100 ft.of . ands:
0 Yes . 0 Yes 10 i o