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HomeMy WebLinkAboutBLD-22-005317 A CIINITAIA)V\ CI ' ( ' I.(, ONE & TWO FAMILY ONLY- BUILDING PERMIT Town of Yarmouth Building Department .:''oF....44. )4 1146 Route 28, South Yarmouth,MA 02664-4492 508-398-2231 ext. 1261 Fax 508-398-0836 il 1411 Massachusetts State Building Code, 780 CR M =, \ e Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: B 0)--22-0.5.317 Date Applied: Building Official(Print Name) Signature Date (S'(p #4,) SECTION 1:SITE INFORMATION iz 1.1Property Address 1.2 Assessors Map&Parcel Numbers RE C E I V E D Tr (o So writ No,26 7 Li Is this an accepted street?ye no Map Number Parcel Numbe nq 1 1.3 Zoning Information: 1.4 Property Dimensions: R 2 2 1UL2 Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) a BY. UILDING DEPARTMENT 1.5 Building Setbacks(ft) - 3 s-;OO Front Yard Side Yards I Rear Yard j(/� Required Provided Required Provided Required Provided l:�F- 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public 0 Private 0 Zone: Outside Flood Zone? — Municipal 0 On site disposal system 0 Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: Joyce tC>egc_,ry TR-.usT WS_y/pociTW MA- oz/8a ✓ Name Print) City,Stat ,ZIP /35-P ernv a ,-7- Z/- // mAQi- ' T (a) C)mc., ;. Ai& 7— No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction 0 Existing Building{ ' Owner-Occupied 0 Repairs(s) 0 Alteration(s) L3 / Addition 0 Demolition ❑ Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Work'JCc..& )^/ e k iSN/v 4. 2E&.A / CD k&move Ce it_inI ;v L/e t.erIvE roieboZ 1L V SECTION 4:ESTIMATED CONSTRUCTION COSTS Estimated Costs: j Item (Labor and Materials) Official Use Only 1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee ❑Total Project Costa(Item 6 x multiplier . . x 3.Plumbing $ 2. Other Fees: $ c'L ISV 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire Suppression) $ Total All Fees:$ / Check No. Check Amount: Cash Amount: v 6.Total Project Cost: $ ',,, ❑Paid•in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) Lc-�.)4R 6 1 'C-_7„►© %� License Number Expiration Date Name of CSL Holder if Q / ' A-i No.and l Stree`t', S List CSL Type(see below) / Type Description SO q Ti+DelvN; ©2 4, 6 U Unrestricted(Buildings up to 35,000 cu.ft.) R Restricted I&2 Family Dwelling City/Town,State,ZIP M Masonry / RC Roofing Covering •V WS Window and Siding - 8 20$ of L R3 Lb,� SF Sold Fuel Burning Appliances ��' 3 f' u� I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) L R 3 2L/i'L D'A�) Co S 7 ''NE L A)t Sw e-s HIC Registration Number Expiration Date HIC company Name or HIC Registrant Name 4 m1( Alikv sT No. St r and Street �, �f pO a. �. 1 D e-NAJ I$ ,)A- C1'2 tip $-7 8 Email address V City/Town,State,ZIP Telephone SECTION 6:WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6)) 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 0 No 0 SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize LD AJI-SeA e - 0 to act on my behalf, in all matters relative to work authorized by this building permit application. ,&j ,-i rJ G� 3 - 2 2 - Print Owner's Name(ElectYonic Signature) Date SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. Print Owner's or Authorized Agent's Name(Electronic Signature) Date NOTES: 1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program can be found at www.mass.aov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dps 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch) Gross living area(sq.ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" • The Commonwealth of Massachusetts Department of Industrial Accidents 1:'Jr-. —' Office of Investigations ! . = �� Lafayette City Center _tt �I ram .''/ 2 Avenue de Lafayette, Boston,MA 02111-1750 �� � wwrv.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): G-,4---3 ' a' �,/ .s.6, } `-e_ t- Address: ( - ani,' Sf '"- 0_0, •-r ;47 A �z c.e-i—c_C City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.p I am a employer to er with Z 4. ❑ I am a general contractor and I 6. ❑New construction employees (full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These subcontractors have 8. 0 Demolition working for me in any capacity. employees and have workers' 9. 0 Building addition [No workers' comp. insurance comp.insurance. required.] 5. ❑ We are a corporation and its 10.171 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.0 Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. *Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. / Insurance Company Name: ,4iM / �c`hu Policy#or Self-ins. Lic. #: v-o S-1)Z tl-C-`l - Z v Z Z PI Expiration Date: 3/ (2 / 2 3 Job Site Address: Sb a rat --5 2-C,-- D _ City/State/Zip: Si) y,A.r io ct irl /14 4- Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signature: G-7Lc.we-t?, Date: 3/2 z/2 0 L-- Phone#: (C-6' ' ) =723 7 `lam Es.-7-- Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(check one): i❑Board of Health 20 Building Department 3.DCitylTown Clerk 4.0 Electrical Inspector 5E}lumbing Inspector 6.0Other Contact Person: Phone#: 1 Offi Affairs&Business ce • oM OV ENT Cam" • TYPE, LEONARD R RENT, LEONARD At0 at N17ASH DR SOU HMS.&AA =`EE' fOr Commonwealth of Massachusetts Division of Professional Licensure Board of Building.Regulations and Standards ConStRtCCt 71'$tlperVISOr CS-113102 Upires 02 1 J22 LEONARD R RENO.III 17 ASHKINS DRIVE SOUTH DENNIS MA 02660 ;. Commissioner Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: LLC Registration: 202898 LR3 BUILDING AND FINE FINISHES LLC Expiration: 08/22/2023 494 MAIN ST SOUTH DENNIS, MA 02660 Update Address and Return Card. Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:LLC before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 202898 08/22/2023 1000 Washington Street -Suite 710 LR3 BUILDING AND FINE FINISHES LLC Boston,MA 02118 • LEONARD R, REND ,�` ,.� �,� - 494 MAIN ST zii*°"'ief� �/a/e4,04• SOUTH DENNIS,MA 02660 Undersecretary Not valid without signature _ TOWN OF YARMOUTH z+..• rC BUILDING DEPARTMENT . 03 1146 Route 28,South Yarmouth,MA 02664 ccA "tea,„„�, 508-398-2231 ext. 1261 Fax 508-398-0836 BUILDING DEPARTMENT / DEMOLITION DEBRIS DISPOSAL AFFIDAVIT Pursuant to M.G.L. Chapter 40, Section 54 and 780 CMR, Chapter 1, Section 111.5, I hereby certify that the debris resulting from the proposed work/demolition to be conducted at .5-6 £c/rt+ Srksa E VC--; Work Address Is to be disposed of at the following location: e�N,rim:JD;s as Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. r. Am. z Signat AOp ' ation Date Permit No. Sears, Tim From: Sears,Tim Sent: Wednesday, April 6, 2022 8:17 AM To: 'rob@Ir3build.com' Cc: Grant, Kelly;Water Department Subject: 56 South Shore Drive Attachments: work in flood zone packet.PDF Leonard, I have reviewed your application for the renovations, and there are some items needed; 1. Conservation sign off 2. Water Department sign off �3 Your CSL is expired 4. This property is located in a flood zone, please review attached packet. We need the cost worksheet filled out, contractor&owner affidavits signed and notarized.The final affidavit is not needed until the completion of work. Please submit these items for review This email is considered a written denial of your permit application per Section 105.3.1 of the Massachusetts State Building Code. Section 105.3.2 states in part that "an application for a permit for any proposed us k shall be deemed to have been abandoned 180 days after the date of filing, unless such application has been pursued in good faith" You may appeal this denial to the Building Code Appeals Board in accordance with M.G.L. c. 143 §100,within 45 days of this notice. i imothy Sears CBO Deputy Building Commissioner Town of Yarmouth 508-398-2231 Ext. 1259 mailto:tsears@yarmouth.ma.us 1 Property Location 56&60 SOUTH SHORE DR Map ID 19/25/// Bldg Name State Use 1090 Vision ID 884 Account# 884 Bldg# 1 Sec# 1 of 1 Card# 1 of 2 Print Date 8/12/2021 CURRENT OWNER TO_PO UTILITIES STRT/ROAD LOCATION CURRENT ASSESSMENT JOYCE ELIZABETH A 1 Level 1 Paved 2 Suburban Description Code Assessed Assessed 815 RESIDNTL 1090 203,400 203,400 RES LAND 1090 565,600 565,600 135 ACADEMY AVE SUPPLEME'N AL DATA YARMOUTH,MA Alt Prcl ID 15/R002/// VOTE WEYMOUTH MA 02188 MISC 160 VOTE DATE CHANGES ' VATS BETTERMENTS VISION PLAN # 517A ZIP CODE 2664: GIS ID M_306856_821722 Assoc Pid# Total 769,000 769,000 RECORD OF OWNERSHIP BK-VOL7PAGE . SALE DATE VII- SALE PRICE - VC PREVIOUS ASSESSMENTS(HISTORY% JOYCE ELIZABETH A D 1266629 0 04-06-2015 U I 100 1 F Year Code Assessed Year Code Assessed V Year Code Assessed JOYCE ELIZABETHATRS 24212 ' 180 12-04-2009 U I 100 1F 2022 ' 1090 203,400 2021 1090 172,100 2020 1090 151,400 JOYCE ELIZABETH A 46342 0 11-18-1955 I 0 1090 565,600 1090 531,300 1090 507,900 JOYCE ELIZABETH A 0 I 0 - 1090 2,000 Total 769000 Totar 703400 Total' 661300 EXEMPTIONS OTHER ASSESSMENTS This signature acknowledges a visit by a Data Collector or Assessor Year Code Description Amount Code Description Number Amount Comm Int APPRAISED VALUE SUMMARY Tota!, v•wl I I appraised Bldg.V !ue(Card) I 199,800 I I ASSESSING NEIGHBORHOOD Appraised Xf(B)Value(Bldg) 1,600 Nbhd Nbhd Name B Tracing Batch Appraised Ob(B)Value(Bldg) 2,000 0070 NOTES 'Appraised Land Value(Bldg) 565,600 WEATHERED&WHITE I/A 019.50 EXEMPT ADDED LAND Special Land Value 0 GOOD OCEAN VIEW TO THIS LOT Total Appraised Parcel Value 769,000 56 SOUTH SHORE DR Valuation Method C Total Appraised Parcel Value 769,000 BUILDING PERMIT RECORD • VISIT/CHANGE HISTORY Permit Id Issue Date Type Description _ Amount Insp Date %Comp Date Comp Comments - Date Id Type Is Cd Purpost/Result 16-001077 08-25-2015 SD Shed 4,800 01-01-2016 100 10 x 14 shed-subject to zonin ' 03-31-2020 ' WD 54 Field Review 01-764 05-02-2001 RS Residential 7,500 03-11-2002 100 ADDITION 05-11-2016 CW CL Cyclical 01-763 05-02-2001 RS Residential 2,500 100 01-01-2002 CATH CEILING&WINDOWS 01-11-2016 LS BP Building Permit 00-951 06-07-2000 RS Residential 9,500' 04-24-2001 100 01-01-2001 EXTEND PORCH&ADD DEC 01-01-2014 BH 01 1 CY CYCLICAL 2014 514 07-10-1995 RS Residential 1,460 04-17-1996 100 01-01-1996 SHED 04-07-2003 GM 00 Measur+Listed 03-11-2002 KF 00 Measur+Listed 04-24-2001 KF 00 Measur+Listed LAND LINE VALUATION SECTION B Use Code Description Zone Land Type Land Units Unit Price Size Adj Site Index Cond. Nbhd. Nbhd.Adj Notes Location Adjustment Adj Unit P Land Value 1 1090 MULTI HSES M 25,700 SF 4.94' 1.00000 7 0.90 0070 1.650 '10%EASEMENT WF3 1.0000 22.01 565,600 1 - Total Card Land Units' 25 7001 SF' Parcel Total Land Area 0.5900 Total Land Value' 565,600 Property Location 56&60 SOUTH SHORE DR Map ID 19/25/// Bldg Name State Use 1090 Vision ID 884 Account# 884 Bldg# 1 Sec# 1 of 1 Card# 1 of 2 Print Date 8/12/2021 CONSTRUCTION DETAIL _ CONSTRUCTION DETAIL(CONTINUED) Element Cd Description Element Cd Description Style: 01 ~Ranch BAS Model 01 Residential Grade: 02 Below Average Stories: 1 1 Story Occupancy CONDO DATA Exterior Wall 1 14 Wood Shingle Parcel Id ICI Owne 0.0 WDK Exterior Wall 2 JB is Roof Structure: 03 Gable/Hip Adjust Type Code Description Factor% Roof Cover 03 Asph/F GIs/Cmp Condo Fir Interior Wall 1 05 Drywall/Sheet Condo Unit Interior Wall 2 COST/MA RKET VALUATIO 16 Interior Fir 1 09 Pine/Soft Wood 31 Interior Fir 2 14 Carpet Building Value New 159,898 Heat Fuel 01 Coal/Wd/None Heat Type: 01 None AC Type: 01 None Year Built 1926 Total Bedrooms 03 3 Bedrooms Effective Year Built 20 Total Bthrms: 1 Depreciation Code A 1 FEP 8 Total Half Baths 0 Remodel Rating Total Xtra Fixtrs Year Remodeled Depreciation% 32 e Total Rooms: Functional Obsol 0 Bath Style: 02 Average Ext.Comment 0 25 Kitchen Style: 02 Modern Trend Factor 1 16 14 Condition Condition 8 Percent Good 68 RCNLD 108,700 Dep%Ovr 22 Dep Ovr Comment Misc Imp Ovr i+ V , �e , Misc Imp Ovr Comment ;„ - ' , Cost to Cure Ovr x v, ! - ' '.r - �'ti.' Cost to Cure Ovr Comment 4 „,+ '� $ ? '�"A;, - x iw OB-OUTBUILDING& YARD ITEMS(L)I XF-BUILDING EXTRA FEATUI2ES(B) ..' - Code Description LIB Units Unit Price Yr Bit Cond.Cd %Gd Grade Grade Adj. Appr.Value .. �` , EOS End Outs Shw B 1 0.00 1983 68 0.00 0 SHD2 W/LIGHTS ET L 120 9.00 1996 90 0.00 1,000 SHD1 SHED FRAME L 140 8.00 2015 90 0.00 1,000 . ''' .' ' '.'T--st.-- \ -1}7-f., , BUILDING SUa-AREA SUMMARY SECTION " Code Description Living Area Floor Area Eff Area Unit Cost Undeprec Value -i BAS First Floor 775 775 775 164.00 127,098 �r FEP Porch,Enclosed,Finished 0 240 168 114.80 27,552 WDK Deck,Wood 0 320 32 16.40 5,248 ems- 4 ii: ,- -4 }.7� �+ Ttl Gross Liv/Lease Area 775 1,335 975 159 898 .-_ '-" �.* x,;*.o. - g' * - "_ ," = - , Property Location 56&60 SOUTH SHORE DR Map ID 19/25/// Bldg Name State Use 1090 Vision ID 884 Account# 884 Bldg# 2 Sec# 1 of 1 Card# 2 of 2 Print Date 8/12/2021 CURRENT OWNER TOPO - UTILITIES STRT/ROAD LOCATION CURRENT ASSESSMENT JOYCE ELIZABETH A 1—Level 1 Paved 2 Suburban Description Code _ Assessed Assessed 815 RESIDNTL 1090 203,400 203,400 - RES LAND 1090 565,600 565,600 135 ACADEMY AVE SUPPLEME TAL DATA YARMOUTH,MA Alt Prcl ID 15/R002/// • E WEYMOUTH MA 02188 MISC 160 • E DATE CHANGES PRIVATE BETTERMENTS PLAN # 517A ZIP CODE 2664: GIS ID M_306856_821722 Assoc Pid# Total 769,000' 769,000 RECORD OF OWNERSHIP BK-VOLIPAGE SALE DATE VII SALE-RICE VC PREVIOUS ASSESSMENTS(HISTORYf JOYCE ELIZABETH A D1266629 0 04-06-2015 U I 100 1F Year Code Assessed Year Code Assessed V Year Code Assessed JOYCE ELIZABETH A TRS 24212 180 12-04-2009 U I 100 1 F 2022 1090 203,400 2021 1090 172,100 2020 1090 151,400 JOYCE ELIZABETH A 46342 0 11-18-1955 I 0 1090 565,600 1090 531,300 1090 507,900 JOYCE ELIZABETH A 0 I 0 1090 2,000 Total 769000 Total 703400 Total 661300 EXEMP17ONS OTHER ASSESSMENTS This signature acknowledges a visit by a Data Collector or Assessor Year Code Description Amount Code Description Number Amount Comm Int APPRAISED VALUE SUMMARY I Total. 0 00i I I I j Appraised Bldg.Value(Card) 199,800 ASSESSING NEIGHBORHOOD Appraised Xf(B)Value(Bldg) 1,600 Nbhd Nbhd Name B Tracing Batch Appraised Ob(B)Value(Bldg) 2,000 0070 NOTES Appraised Land Value(Bldg) 565,600 RENOVA Special Land Value 0 Total Appraised Parcel Value 769,000 60 SOUTH SHORE DR Valuation Method C Total Appraised Parcel Value 769,000 B-UILDING PERMIT RECORD VISIT/CHANGE HISTORY Permit Id Issue Date_ Type Description _ Amount Insp Date %Comp Date Comp _ Comments Date Id Type Is Cd Purpost/Result LAND LINEVALUATTON SECTION B Use Code Description Zone Land Type Land Units Unit Price Size Adj Site Index Cond. Nbhd. Nbhd.Adj Notes Location Adjustment Adj Unit P Land Value 2 1090 MULTI HSES M 0 SF 11 1.00000 ' 7 3.00 0070 1.650 0.0000 54.45' 0 I Total Card Land Units 0 Sr Parcel Total Land Area'0.5O Total Land Value Property Location 56&60 SOUTH SHORE DR Map ID 19/25/// Bldg Name State Use 1090 I Vision ID 884 Account# 884 Bldg# 2 Sec# 1 of 1 Card# 2 of 2 Print Date 8/12/2021 CONSTRUCTION DETAIL CONSTRUCTION DETAIL(CONTINUED) Element Cd Description Element Cd Description Style: 01 Ranch Model 01 Residential Grade: 02 Below Average 26 0 Stories: 1 1 Story Occupancy CONDO DATA Exterior Wall 1 14 Wood Shingle Parcel Id ICI Owne 0.0 Exterior Wall 2 lB IS Roof Structure: 03 Gable/Hip Adjust Type Code Description Factor% Roof Cover 03 Asph/F GIs/Cmp Condo Fir Interior Wall 1 05 Drywall/Sheet Condo Unit Interior Wall 2 COT/MA KET VALUATION Interior Fir 1 09 Pine/Soft Wood Interior FIr 2 Building Value New 126,479 Heat Fuel 01 Coal/Wd/None 24 BAS 24-- Heat Type: 01 None FEP AC Type: 01 None Year Built 1926 Total Bedrooms 02 2 Bedrooms Effective Year Built Total Bthrms: 1 Depreciation Code G Total Half Baths 0 Remodel Rating Total Xtra Fixtrs Year Remodeled 12 Total Rooms: Depreciation% 28 Bath Style: Functional Obsol 0 Kitchen Style: Ext.Comment 0 Trend Factor 1 Condition Condition% 26 12 Percent Good 72 RCNLD 91,100 Dep%Ovr Dep Ovr Comment Misc Imp Ovr Misc Imp Ovr Comment ' Cost to Cure Ovr Cost to Cure Ovr Comment lI OB-OUTBUILDING& YARD ITEMS(L)/XF-BUILDING EXTRA FEATURES(B) Code Description LJB _Units Unit Price Yr Bit Cond.Cd %Gd Grade Grade Adj. Appr.Value FPL1 FIREPLACE 1 B 1 2200.00 1987 72 0.00 1,600 EOS Encl Outs Shw B 1 0.00 1987 72 0.00 0 a v 1I _ 1 —._'_ BUILDING SUL;AREA SUMMARY SECTION s Code Description Living Area Floor Area Eff Area Unit Cost Undeprec Value BAS First Floor 624 624 624 174.45 108,859 FEP Porch,Enclosed,Finished 0 144 101 122.36 17,620 , _ . ...„- kf,--.,---„,,,-' ,a ' Ttl Gross Liv/Lease Area 624 768 725 126,479 1.v. 1 �; 4 • oy Y'tk TOWN OF YARMOUTH £ lib .-_-44 4 r HEALTH DEPARTMENT PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET To be completed by Applicant. Building Site Location: 5 (o pan-- S> XG ,2,; 1/ - Proposed Improvement: ENC--c-o 5 e -.�r S Ti tJ 6 c e-- 70 M74K-C /I- Paizc./f No /fc q-T- Applicant: /if a rid ) Joyce J/L-- Tel. No.: 6/ ? - ?i / - 93/( Address: /0/ 4 O&/n/4L GU e-xeatiTH AM- Date Filed: 3-2 Z- -..26.),1 **/fyou would like e-mail notification of sign off,please provide e-mail address: Owner Name: Dore - �.4- itt s7— Li 714 E--7W Jo.yee M/7jit) jjcycs J2 Owner Address: /3fi"---//«O e-, y ,i' i / - N1 c/7 7/ /ii/4 Owner Tel. No.: 6/7- ?z/ -Q3/f 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: RECEIVED (1.) Site Plan showing existing buildings, water line location, and septic system location; MAR 2 2 2022 (2.) Floor plan labeling ALL rooms within building (all existing and proposed) - HEALTH DEPT. Note: Floor plans not required for decks, sheds, windows, roofing; f g; (3.) If necessary, Title 5 application signed by licensed installer with fee. REVIEWED BY: DATE: 3 —dZ-S `�' Z PLEASE NOTE COMMENTS/CONDITIONS: