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EXPRESS BUILDING PERMIT APPLICAT
TOWN OF YARMOUTH I 'rt .,:_,C E I V E D
Yarmouth Building Department - �`
1146 Route 28 J 7 r;.,_, .; , ,
South Yarmouth, MA 02664 , '+ - 6 A I(508) 398-2231 Ext. 1261 DEpR". :,,
CONSTRUCTION ADDRESS: S S'7j t.�7-LA-0w+ 5 7. '� "
ASSESSOR'S INFORMATION:
Map: G Parcel: �p
OWNER: 62t"4 2 t„NA[2 20 5 et..-►.tuct L‘1, A// , �2 C.'S-Oir- 't-3 Frl
NAME PRESENT ADDRESS � TEL. #
CONTRACTOR:
NAME MAILING ADDRESS TEL.#
❑Residential Commercial Est.Cost of Construction$ 30a°'W
Home Improvement Contractor Lic.# Construction Supervisor Lic.#
Workman's Compensation Insurance: (check one)
qI am the homeowner ❑ I am the sole proprietor ❑ I have Worker's Compensation Insurance
Insurance Company Name: Worker's Comp.Policy#
WORK TO BE PERFORMED
Tent '✓ Duration 1 trO GAYS (Fire Retardant Certificate attached?) Wood Stove
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:
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 revo do of my license and for prosecution under M.G.L.Ch.268,Section 1.
Applicant's Signature: c Date: Z - l 3` 2-e
Owners Signature(or attachment) q9. --, Date: 2- t3~'L0
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Approved By: , ln �-- Date: - O A ,0
Building Official(or designee) EMAIL ADDRESS:
Zoning District:
Historical District: ❑ Yes No Flood Plain Zone: Li Yes : No
Water Resource Protection District: Within 100 ft.of Wetlands:
❑ Yes ❑ No E Yes _ No
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`,t.-Y4 dy,_ TOWN OF YARMOUTH :4 _
.��� i� HEALTH DEPARTMENT N E:. t16 2020
PERMIT APPLICATION SIGN OFF TRANSMITTA SICEETMI DEPT.
To he completed by Applicant:
Building Site Location: 5 ' t «C-'.v S S'-
Proposed Improvement: T;e: Qo..b.24 cy S rciq A Q- S r./1-4-0`'r t 2 1r 2 2 V — 3 o'M
12 x 3o X 13 tt NPPAcr sCze, RA-27-<<- t=c.o-ems
Applicant: r-'- ' u I ' - Tel. No.: S ob-c7?- ?c i
Address: 20 5 i'ft-" ce I-AV- Date Filed: 2 -C,. 2 0
**/f you would like e-mail notification of sign off please provide e-mail address:
Owner Name: AtLT1+v/< r-�fGC
Owner Address: S 1)'M2 Owner Tel. No.: 5 k^Z 1'
RESIDENTIAL AND/OR COMMERCIAL BUILDING
HEALTH DEPARTMENT: Determines Compliance to State and Town Regulations; i.e., Requirements
For Septage Disposal and other Public Health Activities.
Please submit three (3) copies of plans, to include:
(1.) Site Plan showing existing buildings, water line location,
and septic system location;
(2.) Floor plan labeling ALL rooms within building
(all existing and proposed) —
Note: Floor plans not required for decks, sheds, windows, roofing;
(3.) If necessary, Title 5 application signed by licensed installer
with fee.
REVIEWED BY: ec i + 1, DATE: 2' /3-
PLEASE NOTE
COM NTS/CONDITIONS:
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TOWN OF YARMOUTH BUILDING DEPARTMENT
•° —44 APPLICATION FOR DETERMINATION OF NON-APPLICABILITY
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• I 4' AQUIFER PROTECTION BYLAW §406.5.1.1
FEB 0 6?020
Applicant/Business Name: LQ Kt. sac t'4 t 2 Date: 2-- 2
;LTh
Property Owner: 1'�Y N VA- I-- .<�
Property location: 5-5-0 << Low '�i Unit# Map&Lot#
Proposed Use: T r^&P T a,.t r s
I. Has applicant has fully complied with the Submittal Requirements of§406.5.2 ?
(Attach copy of Hazardous Materials List)
2. Does the proposed use meet all of the Design and Operation requirements of§406.5.7,
3. Are the chemicals, pesticides, fuels and other potentially toxic or hazardous materials used or
stored at the site, or produced by the proposed use, in qualities not greater than those
commonly associated with normal household use,
4. Does the proposed use meet all of the objectives and water quality criteria of the bylaw: t'tedur"2--
The above applicant hereby acknowledges that the Building Inspector may require the applicant to submit the
matter to the Health Agent or Board of Health,and may require the applicant to demonstrate that he/she has
received a favorable report from the Health Agent or Board of Health. The Determination,if made,shall apply
only to the individual applicant and proposed use and shall automatically expire upon any change of use or
transfer of ownership of the business. There shall be no appeal from an unfavorable Determination of any such
application,nor from a failure to act,except for filing by the applicant for a Special Permit from the Board of
Appeals as otherwise provided herein.
rz FK Lv:�Z 2 -6•2v
Applicant Date
(=2�K �JsLL�
Print Name
DETERMINATION: The Building Inspector, based upon a review of this application and information
supplied by the Applicant,hereby determines that the proposed use satisfies the requirements of§406.5.1.1 and
that the Applicant need not apply for a Special Permit under§406.5
C-4/PoGe# 2-13 2020
Building Inspector Date Health Agent Date
Form must be filed with the Town Clerk and copies of this form must be sent to the following
departments(as listed in§406.5.4); Water,Engineering,Fire,Health,Planning,Conservation,Board of
Appeals.
Aquifer Protection District Waiver 05/08
rat) vie
TO: Commercial Applicants in the APD
(#1 • FROM: Yarmouth Health Department
SUBJECT: Hazardous Materials
As pert of the application process for a Board of Appeals hearing or Determination of Non-Applicability,
please complete this form and return it with your application. For further information concerning hazardous
materials regulations,contact the Health Department Office.
In the conduct of your present and/or proposed business, do you store, use, generate any of the
following types of products? Please check all which apply and list quantities.
Antifreeze, Engine dr. Radiator Flushes Motor Oil
Hydraulic, Brake,Automatic Trans. Fluid Gasoline/Fuels
Grease,Lubricants Degreaser/Cleaners
Floor/Driveway Degreaser Battery Acid
Rustproofing/Undercoating Vehicle Detergents
Vehicle Waxes,Polishes Asphalt, Tar, Sealer's
Paint, Varnishes, Stains, Dyes, Thinners Wood Preservatives
Dry Cleaning Solvents,Carbon Tetrachloride Floor/Furniture Strippers
Other Cleaning Solvents Rock salt, Road salt
Drain, Toilet, Cesspool Cleaners Refrigerants
Bug& Tar Removers Photo chemicals
Printing Inks& Dyes Pool Chlorine
Pesticides, Insecticides, Herbicides Rodenticide, Fungicides
Nitrate Fertilizer Jewelry Cleaner
Leather Dyes PCB=s
Electroplating Sludges Others (List)
Applicant Signature: Date: 2 6 2 a
00(q 5 &I- A
HEAL TAPDDETER I O-99
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