HomeMy WebLinkAbout2009 Sep 21 - Building Permit Packet , o • 4ii ONE &TWO FAMILY ONLY- BUILDING PERMIT .. .
• ' _• C APPLICATION TO CONSTRUCT,REPAIR,RENOVATE OR DEMOUSH A ONE •,: TWO FAMILY OWELUNG
.' p p�'4A, „5 Town ol'Yarmouth Building 1)cpartment
1.11r ? 11.16 Route 28 • Yarinouth.11,102661-)192
• el: (5I)1):W8.2231 x261 • Fax: (508) 398-0836
Dolce Use oN q Planning Board Information Assessors Department Information:
Permit No73:1" Dale Plan TY" '►�° !L
Permit Fee $ Endorsement Date l�O/ G c
1.0......ilinq DateDeposit Reed. $dDat )Ian No. 1.4 Propertlt Dimensions:
Net Due $ 7other Lot Anna(st) Frontage(It) Lot Coverage
.
. .' . : • TMs Sidon for Office use Only ••• • .. .
Building Pe � � Date Issued:
g� "4 : . . "211'aq. .CertlIlcats of Occupancy
Si lure• •
` . , 011tdsi • . Deb Is M not required
Section 1 •She Information j Use Group:R-4 'Type:5-B .
1.1 Property Address, e fi
d 1.2 Zawq Information:
4e21 13Iue . g t�
S": yav'ivol eV, f Zoning District Proposed Use
1.3 Building Setbacks lit) ,
Front Yard Side Yards Rear Yard
Required Provided _ Required Provided Required Provided
1.4 Water Supply(UAL a.40.$s4)11.5 Flood Zone Informed= Comma rta
Public Private I •• Zone: BFE:
Section 2-Property Ownership/Authorized Agent I .
• Z1 Own ei Reeao.
L% F lIFPS oil (t gd< 2, CV&MI,
Name Iw+ /79"2:00,,,. Mailing Address
aebuch.csd <0O• 76.0. 3BgZ,--
Signature ...2.S Authorized AgentsTelephone r o2 La • Y9�^�—
•
Name(pint) Mailing Address
Signature Telephone Fax
Section 3-Construction Services I
3.1 Lkensed Construction Supervisors Not Applicable U
O.
tI License Number
Address V
t
till Expiration Oats
Signature __._...�.. Telephone 1 .
•
(3.2 Registered Home Improvement Contractor: 550
I Cly Manse Sf Not Applicable 0
License Number
Address •
• • • Expiration Date——
Signaturet Tdephone
1 of 2 OVER
, • Section*.Workers'Compdntatioh Insurairoe Affidavit(KM:6 152825D(etI ' . •
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 S'-Dtiscriptibtt of Proposed Work(check al applicable)
New Construction 0 J No.of Bedrooms No.of Bathrooms 1
Existing Bldg. ❑ 1 Repair(s) ❑ Alterations ❑ Addition ❑
I
Accessory Bldg. ❑ Type Demolition Other Specify:
Brief Description of Proposed Work:
t� ,
�� C��tt�1�t in k���e.+ t...✓ ac�.d( Hc,o4�
b, Re t tae.. pc) or'.. of we.1,1
mactie. " Co-�.lve�� : i�.$17,jf ,2 j fiyhls•
/AU) uJ f✓f'{ $e GJ /,w ./A r b't^
Section S.Estimated Construction Costs
Item Estimated Cost(Dollars)to be- • . • • .Check Below
completed by permit applicant •
1.Building ❑ Conservation-Commission Filing
2.Electrical (if applicable)
a.Plumbing/Gas f •
4.Mechanical(HVAC) ❑ Old Kings Highway&Historical
5.Fire Protection Commission approval
6.Total w(1 +2+3+4+5) (!applicable)
T.Total Square Ft.(no Num t aask re) •
Section Ta-OwnerAuthbdzatlon To be Completed Wheal
;•• Owner's Agent or Contractor App lies 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.
Signature of owner Date
Section 7b-Owner/Authorized Agent Declaration
l• V '�~ ,as Owner/Authorized Agent
hereby declare that the statements and information on the foregoing application are true and accurate,
to the best of my knowledge •
Signed under the pains and penalties of perjury. • /.
•
Print nameati,A1
Signature oi• /A ent
9n g Date
•
9.15.99 2of2
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