HomeMy WebLinkAboutImage_003.pdf - BLDX-23-15545 22208Permit#
Office Use Only
Permit exptes I E0 days from
issue date
EXPRESS BUILDING PERMIT APPLICAT ECE!VE D
TOWN OF YAfu\{OUTH
Yarmouth Building Department
I 146 Route 28
South Yarmouth , MA 02664
(508) 398-2231 Ext. 1261
30 2023i ocl
#,n*V.uo*r,4n
CONSTRUCTION ADDRESS:
AS SE S S OR' S INTOfu\LA.TION :
I
Map Parcel
O\'!NER C
Nfu\TE PRESTNJT .4.DDR-ESS TEL. d
CONTRACTOR
NA-\tE
O Resideotial i Commercial
Home Improvemenr Cootractor Lic. # / ? S-
Tent _ Duration
Siding: # of Squares
Construction Supe
I have Workea's Compensation Insuralce
Worker's Comp. Policy#_
rvisor Lic. # C (-a q lrC o
t t-/Y-ut
Pool fencins
Ot)(.l267.
{o8c1z71g 6z_
lvL{JLIN RESS
/e-
Est. Cost of CoNrruc(ion $
L
tL?t
workman's Compensation lnsurance: fche.t on"; V-2"4-LY
f I arn lhe homeowner dl am rhe sole proprieror -
Insurance Company Namc:
Roofing: # of Squares
_ Old Kings Highrvav./Historic Dist. ( ) Replacing like for like
'Th€ debris will b€ disposed ofar:
tion of F.ciliD
Applicanr's Signature
Owoers Signature (or rttachmen
Approved By
lding Official (or designee)Elvlr\IL ADDRESS
f'
I decla'e under penalties ofpcrjury that thc sta(cmenls hercin contained are true and conect ro the_best ofmy knowledgc and beliei I understand that any false answe(s)wrll bejust cause for denial or revocation ofmy liccnse and for prosecution ,rao vrr,L. cr,. zrs. s".,i", r
Date
DIl te
Date
Zonirg District:
Historical Districr i yes I No
water Resource protection District:i Yes aNo
Flood Plain Zone: a yes I No
Within 100 ft. of Werlallds
O Yes I No
Bur
va..l(-(oY4
i
I
lvood Stoye_
Replacement doors: #_
Insulation
WORKTO BE PERFORI{ED
(Fire Retardant Certificate attached?)
Replacement windows: #-_
( ) Remove existing* (max.2layers)