HomeMy WebLinkAboutBld-20-004057 1
Office use Only
* Permit# 2
Amount 3s
e"' Permit expires 180 days from
BLI -40-i--tr ---/
issue date
EXPRESS BUILDING PERMIT APPLICATION'
TOWN OF YARMOUTH
Yarmouth Bui-iding Department R E C E I V E.� _�,
1146 Route 28' _ � i
South Yarmouth, MA 02664 JAN 23 202
(508)398-2231 Ext. 1261 r
CONSTRUCT ION ADDRESS: e U 1 LclaVfP
ASSESSOR'S INFORMATION
Map: lIlL' Parcel;
owisrE .: /1 1 1 ' (o L.0 17ct Cc.:a 3. t=- c 4--c t 1L.Q f�, i;
AME PRESENT ADDRESS TEL. #
CONTRACTOR .. . L ?TEL%7
t t�'yl fNAME
1GaResidential 0 Commercial Est.Cost of Construction$ 1/(40
Some Improvement"Contractor Lie.# j Q S Construction Supervisor Lic,# 1 O '-/
Workman's Compensation Insurance: (check one)
0 I am the homeowner. 0 I am the sole proprietor 4iior<ve Worker's Compensation Insurance '
Insurance Company Name: Worker's Comp.Polic''y,LA ? J
WORK TO BE PERFORMED
Tent Duratioe (Fire Retardant Certificate attached?) Wood Stove
Siding: #arSquares ' Replacement windows:# Replacement doors: #
Roofing: #of Squares ( )Remove existing*(max.2 layers) Insulation __
Old Dings Highway/Historic Dist. ( )Replacing like for like Pool fencing
*The debris will be disposed of at:J Wit% % € 1AELLA H 171A n
Location of Facility,
I declare under penalties of perjury that the statements 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 revocation of m ,d prosecution under M.O.L.Ch,268,Section I.
Applicant's Signature: w Date: I Oa/
Owners Signature(or attachment) Date:
Approved By:
Date: /'dk �O �v
Building Official(or designee) EMAIL ADDRESS:rillnt �"l,# ., 4*-.Vf a ++ 1
Zoning District
Historical District: 0 Yes 0 No Flood Plain Zone: CI Yes 0 No
Water Resource Protection District Within 100 ft.of Wetlands:
0 Yes 0 No ❑ Yes 3 No
RISE.
ENGINEERING'
OWNER AUTHORIZATION FORM
1, Kathleen Leblanc
(Owner's Name)
owner of the property located at:
4 Lexington Lane
(Property Address)
Yarmouthport, MA 02675
(Property Address)
hereby authorize
(Subcontractor)
an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building
permit and to perform work on my property. This form is only valid with a signed contract.
// 2i/-
Owner's Signature
Date
RISE Engineering, a Division of Thielsch Engineering, Inc.
5 Dupont Avenue I South Yarmouth, MA 02664 1508-568-1926
www.RlSEengineering.com
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