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HomeMy WebLinkAboutBLD-23-000385 W--I--/ -- C ' •., & TWO FAMILY ONLY- BUILDING PERMIT FIECEIV Town of Yarmouth Building Department ;, oF..`_r -" 1146 Route 28, South Yarmouth, MA 02664-4492 ' \.* JUL 25 2t122 1 508-398-2231 ext. 1261 Fax 508-398-0836 Massachusetts State Building Code, 780 CMR1%,i* : __.._ D %,,i g 'ermitA lication To Construct, Re air, Renovate Or Demolish EPAR gU{LCjING In PP P By ---T a One-or Two-Family Dwelling This Section For Official Use Only - Building Permit Number: 13(z 23- D b S � Date Applied Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 1.1 a Is this an accepted street?yes X no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(It) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required ® E 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Dis 3os 1 S stem: Public 0 Private 0 Zone: '' Outside Flood Zone? �I'(ry l C� wry) if yes❑ Municipal❑ On sit z is o ys em `L�' SECTION 2: PROPERTY OWNERSHIP' BUILDING DEPARTNENT 2.1 Owner'of Record: By __ ._ m_.____ )0q e(Print) CI State, IP di 1� © © No. and Street ur`r���v2 (,(V((��-- � sad` 92 s gO TelephoneEmail Address SECTION 3:DESCRIPTION OF PROPOSED WORK'-(check all that apply) New Construction 0 Existing Building g Owner-Occupied 0 Repairs(s) INt Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: Brief Description of Proposed Work' R,r t f, &t S ty A of p, LU('-k dc_ Al' tiv ;,r�>..,.,r of R<F " ,t r „,D fi- 3e SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: (Labor and Materials) Official Use Only 1. Building $ ("t 20- 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ NJStandard City/Town Application Fee 0 Total Project Cost3(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ C(C-( , 4. Mechanical (HVAC) $ List: 3Z b.00 5. Mechanical (Fire Suppression) $ Total All Fees:$ 6.Total Project Cost: $ i Check No. Check Amount: Cash ount: L1/ 00 0 Paid in Full MIOutstanding Balance D e: i 9 0 5:1-b \ ,� ,e12 SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) A j LS -- 11, b1 3 1./� 05, wtiw N- ai .� L License N mb r E iration`Date Name of CSL der C ( ��//� List CSL Type(see below) No.and Street Type Description A 'lti:dk44t AAA- •°V� ��41 �� Unrestricted(Buildings up to 35,000 Cu.ft.) City/Town,State,ZIP R Restricted I&2 Family Dwelling �1 / Iv' Masonry FD Vr t r �"-('�` `�'"rp RC Roofing Covering ,,,n WSCO Window and Siding 2 V V 1 SF Solid Fuel Burning Appliances ( jj 'k Fd G4,,ti kas„a e cs I 1 Insulation TelephoneEmail addresl D I Demolition 5.2 Registered Home Improvement Contractor(HIC) ?ate. E'j-}gcLwo�..._ 67, "t to h` 1 c)R3 16 5 FTC'C?ay Et or HIC Registrant Name HIC egistration Number E. ira i n to t No. and "eet r- ' RP LY. v t'.L. mail addre s relrc Alt/`-- 09 �b C} Cit.I Li 26'0?0 4 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 Roily , / to act on my behalf, in all matters relative to work authorizedis building permit application. 21- 4 -in t Owner's Name(Electronic 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. 22- Print 0 er's or Authorized Agent's e-(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.eov/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.) ga(includingrage,arage, 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 l �}o_► ft, Department of Industrial Accidents 'l"�‘1 , 1 Congress Street, Suite 100 Boston, MA 02114-2017 :� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): f to k C3 Address: 2 400,/,. t� o f s City/State/Zip: 4-441( MA- 0 045 Phone #: , -it 3''2_ .1., 1 Are you an employer?Check the appropriate box: Type of project (required): L❑I am a employer with employees(full and/or part-time).* Li 2XI am a sole proprietor or partnership and have no employees working for me in 7. New construction any capacity. [No workers'comp. insurance required.] 8. ❑ Remodeling 3.0 I am a homeowner doing all work myself. [No workers'comp. insurance required.]t 9 E Demolition 4.E I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 ❑ Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.] Electrical repairs or additions proprietors with no employees. 5.E I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 12.❑Plumbing repairs or additions These sub-contractors have employees and have workers'comp. insurance.: 1 ❑Roof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no employees. [No workers'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: /✓ i Policy#or Self-ins.Lic. #: i1x1--yi 2�r_ /� � °y•- r Expiration Date: �� l� c�/9� Job Site Address: / City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL, c. 152, §25A is a criminal violation punishable by 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$250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and enalties of perjury that the information provided above is true and correct. Signature: 1/4_„ > Date: Phone#: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: ' TOWN YARMOUTH �� BUILDING DEPARTMENT o . MATTI.CNECiE/ 4i 11.46 Route 28 South Yarmouth, MA 02664 508-398-2231 ext. 1261 HOMEOWNER LICENSE EXEMPTION PLEASE PRINT: DA 1'h:JOB LOCATION: IO 7 g i‘liih )VA-- A) vie Ir�- S g.yax rti a Mk 0_664 NAME STREET ADDRESS SECTION OF TOWN "HOMEOWNER" A e,Kitt 47. S Q$ -/-0 7-$0 3 g NAME HOME PHONE WORK PHONE PRESENT MAILI\iTG ADDRESS I r,1 4,,.Lu/ /rav kv .L eu'(t Yfiit �t.c k,.. AA c-12 66 • C OR TOWN STA lE ZIP CODE The current exemption for `Homeowner' was extended to include owner—occupied dwellings of one or two units and to allow such homeowners to engage an individual for hire who does not possess a license, provided that such homeowner shall act as supervisor. (State Building Code Section 110 R5.1.3.1) Definition of Homeowner: Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is or is intended to be, a one or two family attached or detached structure assessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner;such"homeowner"shall submit to the building official, on a fours acceptable to the building official,that he/she shall be responsible for all such work perfoimed under the building permit. (Section 110 R5.1.3.1) The undersigned `homeowner' assumes responsibility for compliance with the State Building Code and other applicable codes, by-laws, rules and regulations. The undersigned 'homeowner' certifies that he / she understands the Town of Yarmouth Building Department minimum inspection procedures and requirements and that he / she will comply with said procedures and requirements. HOMEOWNER"S SIGNATU , //e----.. // d10- APPROVAL OF BUILDING 01 'ICIAL INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent, which meets the requirements of MGL Ch.142. Yes No If you have checked ves, please indicate the type coverage by checking the appropriate box. A liability insurance policy Other type of indemnity Bond OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner Agent h:homeownrlicexemp TOWN OF YARMOUTH r 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1261 Fax 508-398-0836 Office of the Building Commissioner 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� T. Work Address Is to be disposed of at the following location: ✓`� C / R �?' d1_��7 t Said disposal site shall be a licensed solid waste facility as defined by M.G.L. Chapter 111, Section 150A. -/I 3/2 Sig ature of Applicant Date Permit No. Sears, Tim , From: Sears,Tim Sent: Tuesday, August 2' 20221 8 PM To: 'info@gentekcorp.conn' Subject: 109Seaview I have reviewed your application for the deck replacement,and you are going to need conservation sign off. Thank you Timothy Sears [B(] Deputy Building Commissioner Town ofYarmouth SO8-398-2231 Ext. 12S9 nnoi|to:tsears(@yarmnouth.nna.us z o"--Yak, o. , Conservation Office c --; Town of Yarmouth k pant., ...�.� ,�1'� ,;:.�• th_ma us �' Conservation Commission ` Building Permit Sign-off Application l/ ' r` f I r 1/ AUG , � l -.TO E FILLED OUT BY BUILDING PERMIT APPLICANT - 4 2022 �( 109 Seaview Ave Unit 3, S. Yarmouth MA 02664 :, Building Site Location: 2 Map# Lot(s)# "7 2 C 3 JEANNE HINES 08/01/22 Property Owner: Date filed: Rony el hachem *Applicant. 8 hillside Rd Hull MA 02045 Applicant Address: INFO@GENTEKCORP.COM 781-312-2222 PEmail: Telephone: Ort- Please Note:By submitting this application the applicant grants permission to the Conservation Office to enter the location to conduct a site r it(if needed). Proposed Project Description: Replace existing deck with new wood as well update the footings to code. Site Plan Title/Date: W c1 (AV.,e° S4- U,n‘k" S ` wtuvk ld l f�1 sZ -Z TO BE FILLED OUT BY CONSERVATION ADMINISTRATOR: Does the proposed project require a permit? (-?..- Refer to:SE83- or DOA permit Comments from Conservation Commissio Approved . Conditionally Approved Rejected I - Conservation Commission Sign-off Signature: Date: *TO APPLICANT: All work-related debris shall be taken offsite or disposed in a legal upland location. At the end of each day, the area shall be clean and no debris shall be in the Resource Area. If work is permitted under an Order of Conditions, please arrange a pre-construction site visit with the Conservation Administrator. At the time of site visit, the MassDEP File Number sign must be installed, along with the erosion control/work-limit line. A copy of the Order of Conditions must remain on-site during construction. Please refer to the Order of Conditions for further details. A ® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDp/vYYY) 09/30/2021 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Next First Insurance Agency,Inc. PHO �855�222-5919 FAX PO BOX 60787 (A/ .NNE o.Esti: (A/C,No): Palo Alto,CA 94306 E-MAIL ADDRESS: supportefleXllnsurance.Com INSURER(S)AFFORDING COVERAGE NAIC g INSURER A: State National Insurance Company,Inc. 12831 INSURED Gentek General Contractors INSURER B 8 Hillside Rd INSURER C: Hull,MA 02045 INSURER D INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:7136774 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. PIER ADDL SUER LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MMIIDCDYYFYY) POLICY EXP LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCECLAIMS-MADE I X I OCCUR DAMAGE TO RENTED S1���� PREMISES(Ea occurrence) $100,000.00 MED EXP(Any one person) $10,000.00 A NXTD4EQ3RJ-00-GL 09/29/2021 09/29/2022 PERSONAL B ADV INJURY $1,000,000.00 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $1,000,000.00 X POLICY I I Ea I I LAC PRODUCTS-COMPlOPAGG $1,000,000.00 OTHER; AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) OWNED SCHEDULED BODILY INJURY(Per person) $ AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) UMBRELLA I.IAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ WORKERS COMPENSATION $ AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANYPROPRIETORIPARTNERJEXECUTIVE OFFICER/MEMBEREXCLUDED? ( NIA EL EACH ACCIDENT $ (Mandatory in NH) If yes,describe under E.L.DISEASE-EA EMPLOYEE $ DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $ A Contractors Errors and Omissions NXTD4EQ3RJ-00-GL Each Occurrence: $10,000.00 09292021 09292022 Aggregate: $20,000.00 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Proof of Insurance. CERTIFICATE HOLDER CANCELLATION Gentek General Contractors 8 Hillside Rd Hull,MA 02045 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE n 4.1._ ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD TOWN OF YARMOUTH ti a HEALTH DEPARTMENT ' •_r.r 7. ''--�`` PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET To he completed by Applicant: Building Site Location: f1 r Proposed Improvement: qe. Ts_ Applicant: ,7i h¢,„ . �'Ft k Tel. No.: C,d. /1.2e; Address: Y A,f it ,eft 12 J if J-'A y4 s Date Filed:_4124/2,/ **lf you would like e-mail notification of sign off,please provide e-mail address: Owner Name: 1,0a„nn ,•, es Owner Address: � ,, Owner Tel. No.:C 4� ly 7 7... �? 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: El10VIfsD (1.) Site Plan showing existing buildings, water line location, and septic system location; JUL 2 2022 (2.) Floor plan labeling ALL rooms within building HEALTH DEPT. (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• 1 CA.A, DATE: -- A 5 -) PLEASE NOTE COMMENTS/CONDITIONS: * -*-*-At it .......-....,.. ,,,, t t 4._02_ .. _.... - Aiez".T, LT 7Y: .i..-.'•. • -- K ___ . ,.... E , ,,, c - ,, , ..____ _, . _ - - 1 - tl • .7-..-..-614----_'-':-'T_V-,.'_.•Z..._-'._'A-',_'v''7e-i., •.\\••,. • - • i ! h... , 70 ; ; / I . I . s.-- .;-.'i ' . 1 -r-- . '.RIMINEMIlr C.--;" ' - : ' . — .. "--,' i . V' ' ii . i -•N . ' 3 , . . . 4 ,, - . .- - - -. , -- ,.. 1 • -1 - ' . . ., i,.. • , ..,- - •- -.,.....z._ •--. . - 1-.• ors 1.1 1 . :', „, 1— • ' 1: i' ''' It --' --- -- " I .4.- - .,,,.., . .., . . .ii_...' EtW14.41PESTIVAINV' :4 ' ' I t .• pi ..,.• ,- -- • op,- . ir.1 , 0 t, - 41/ \5 lititelliftWei I ; - . k,, ... 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"17' - '''. ...i..42, 4....', ''.;':- -''',.':'i_0,.:;...1) :: ,!''':,r,g:":',:1'7.:.--:t;',/;1, -, -....1'.dr4.?,-.,..0.... .„,.,.2:..,....AZ.s..,• . - . JUL 2 5 2022 HEALTH DEPT 0. r'' ,f141A , 0 {a # n 3 NX 4 y t 's':ryf 's: ' ',''::' ..'.:.,,::".1,f,,,' . t''. If,--V,,, , .''.,:'"-t .,-, 7 it'', i. '4,—„._ ''''„ \ ,•"k; . I `1 .:,'; "mot ..' " " r tip` i! «f yam' b R ., Yi''' !, ,,.. .. . .... . , . .„ , _ ,. , .., . .. „, „.. . „.„. .. ..... . . , .,.,, , ,, , .. . . t .,,, ... ,,..4..,,,....,::„.„:„......, ,,,,N„.,....,....,. •,: ..--...„,,,,..,,.-,,,,,..4..,;.,,,, „ ... .,,, ...„,..,,,,, , .. . . . "°`" ^ t . . .....,......„.„,,,,........„.,,.._. . . r . , M p . ..,-,,,,..t‘ ........„,......; ti , �,�+y.' Aybi:n d `'✓a',,. Yp'..v��tr ,.. HEALTH DEPT. ,„,.. „--. - , -......",rk,---- :,*,..•-• .-- .--rfs-s..ss--',7,',, ,.•••• „... ..,,,,,-0- :40'.—...`,-"''''..-,:sts,, 2•"' . . .......,...--- •'''• 2M"-'522.2•22'.7. . __ ,.:.,,. , ,,,,,:i.- •2x. 'I ., 4 02; 1 ..tt n!, ... i # • 11 . ..,. . . . I ' ,,,...„ ..6 _ ,.o ..-- ,.-...... .. ''',,,...••.'.;:".':,,,,.„--....,, . • , ,,,s,s4,-,,,,,;,,,,,,s.,.,',":"'s,,!--,-...•,,. , ., , , .•-•;'• , .s......, -„,..... .... siit . ,, .. • ....,..., „... , . ..., . ' ',.. •,,,5:ros,,,,,, : . $' ....., .....„,,,, .2,i'.*!•"!..'4,„ , .',"',,.,,,.Q•,..• .. •-s., JUL 2 9 2022 HEALTH DEPT. 6,6.1're .4'o-1p OF VARvii )LTH /00547Y. , 0-- WATER DEPARTMENT ,9 Buck Wand K,,ad Yar )uth„ViA, 0267 1-712 aks . I- BUILDING PERMIT APPLICATION FOR WATER DEPARTMENT SIGN OPT TRANSMITTAL FORM RI1LDING SITE LOCATION: 10 ti /04-AQ-44:01- AAA c.%),26/6:9 PRON)SED WORK: p4t t APPLICANT: _ 0,1s.c,„ ADDRESS: 8 Ot-tok P,1 H AAA_b_2vi-lic TELPHONE: I — 3 az— RESIDENTIAL AND OR COMMERCIAL BUILDING Water Department: Determines Compliance of Water .-1,railabilit:k and or e:\ist Mg location FtiOneering L)epamnt I),..tcrininvs Compliance for Park*and I)rainage "onservat ion(ommission: I)eiermineN Compliance to Wetlands .,Net: i c [lions>border any type of eilands. streams. ponds,rivers,ocean. bors, ho>s, marshland. ETC... I lealth l)epartinent: I)ctennines Compliance to State and Town Regulations, i.e. requirements tear Septage Disposal and other Public I kali') Activites lire I kpartment: I)etermines sompliance to State and Town Requirements tOr Personal Safety, Property Protections, i.e. Smoke Detectors, Sprinkler Systems,etc APPLICAN *SIGN,1TURE ).VIES;11/9 OFFICE; USE: COMMENTS ON PERNIII.APPROVAL OR DENIAL LA REV A DV V TER DIVISION(SIGNATURE) DATE �6 -. !,:- ,...e,:,.,:r.„.„.,..,.-.,- _ ,..„":-..,,i---,-_,:,.„,,,,,,;..._.::',,--;,,,_ , .:.-0=.7,,,,,,,-,-,,,,,.,,,„-..:_-,,-,,..•-. •.•••----,••,,,,_ ,_.. ,..„14,,,,,:f.,.... • .1„:...,-,5,:;4v.,71-.-..,-;.1-:..",,,,z4i,4.„,,,-..e.t::4,::.;"_.:i ,i,;:zz.:-:.--i.ii-,,,,. A . 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