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EXPRESS BUILDING PERMIT APPLICATION
TO$N OF YARMOUTH
Yarmouth Building Department
I146 Route 2g
South Yarmouth. \[A 02664
(508) 398-2231 Ext. 1261
Oficc Use only
Pcrmit cxpjres 180 day_s from
issue date
)CONSTRLICTIOI( ADDRF,SS
ASSESSOR'S NTOR.\L{T]ON
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Mup arcP
O\T\ER ,-/
PRESEN_'T .{DDR-ESS
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-TNIEt'7-. ,_/'.".//,,-,) /-/,_,.(.z.u r'
CONTLl.CTOR l/,f .ic2 /((1)t\.\\IE \L{]LNG ADDRESS
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EsI. Cost ofConsrruction S
TEL ;
tsResiderrial : Commercial
Home Improv€menr Contractor Lic. # t ll C
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Construcrion Superlisor tx.* ti'0 ilL?i
Workman s Compensation Insurance: [check one)
I I am the homeowner r I am the sole proprieror X I have lvorker's compensarion Insuralce
lnsurance ComDanv \ame /-'/:,t<z-.,.t-4-t
il,4a./ ,(rv.r,,t \\'oRK ro BE pERrotu\rEp l::::_".i:27/:; {-E ?;
rFire Retardrnt certificate attached?,
1':/'" '( /"4/ *;df#,?'' 1l "t'tz</
\& orker's Comp PolicF u.c . &c- l/ ),?C
Replacement doors: F_
Ten I Du ration
Siditrg: * of Squares Replacemen t rr indo* s:
Roo ling: = of 5quares
gnf,Pfio,o',l-n,,,,hn ar 'Ilistoric
( ) Remore eristing" (mar.2 layers)
./Dist. ( trfAeplacing like for like
&, /,2
Pool fencing_
'The deb s wlll be disposed ofar
Lo(arion of Facitit]
I dacla* under penahes ofperjury lh tha slataments harein coorained ara rrue and conect to the bes! of m,lwlll bijun cause for denial or re ocaoon ofml t5 anse and for pr uoon under \{ G L Ch 163. Secrron I
and beliei I undersrand tha! any false ans$eras)
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kno$led_se
Dats.\pphcanr'j Srenalure
Oworrs Signature (or anachm€nr)Drte
DaleApproved By
I ltr aler Resource Protecdon Districr
: Yes :No
Wi$in 100 ft. of Wetlards
' Yes I No
Burldlne OIficral rar deslenee)E\I{JL {DDRESS
Zoning District
Historical District: : Yes , No Flood Piain Zone: - Yes _No
lnsulation
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