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Permit expires 180 days from
issue date
EXPRESS BUTLDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
I 146 Route 28
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261
CO\STRLCTION ADDRESS:
ASSESSOR'S NFOR.\L\TIONi
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NIap Parcel
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RECEIVED
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BU ILDING DTPARTMEN T
NAI,IE PRESENT ADDRESS leu',st1 7'r,l1r,4b 4
CONTR{CTOR L14t
N,lu!tE
,(Residential i Commercial
Home Improvement Contractor Lic. #t
Workman's Compensarion Insurance: (check one)I I am the homeowner Xam the sole proprieror
Lar0(o6ctz-ct> t z-
Est. Cost ofCo$truction S(6-
onstruction Supervisor Lic. #f,f-0t/ tt{za
[<f, 1l,t'l'L7; I have Worker's Compe[sation Inswance
\\.ORK TO BE PERTOR}IET)
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NL,\ILNG ADDRESS
4
Insurance Company \ame
l-cnt Duration
Sidiug: # of Squares
(Fire Retardant Certificate attached?)
Replacement $ indo11s: F_
( ) Remove existing* (max.2layers)
Wood StoYe
Replacement doors: #_
Itrsulation
Pool fencing
worker.s Comp. polic!=
Y br, rn*y Bt, lJus € Xn*', \
Roofing: # of Squares
_ Old Kings Highway/Hisroric Dist. ( ) Replacing like for like
'The d.bris will be disposed or- at:
I declarc under penalties ofpe
will bejust cause for denlal or
Applicant's Signalure:
Buildrng Offiaial (or desi
rjury that the statements herein
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acilft"-
oi t'or
ntained arc true and correct to the best ofmy knowledge and belief. I understand thd any false answer(s)prosecution under VI.C.L. Ch. 258, SecrioD L
/ -b-Z>Date
,[Owoers
Sisnature tor rruchmerr)Date:
Datei
ETLA.iL ,ADDRESS
Zoning District:
Historical Districr: a yes I No
Water Resource Protection Disrict:I Yes lNo Within 100 ft. of Wetlaldsi Yes I No
Approved By
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OWNER:
Loc,rtion
Flood Plain Zone: - Yes No