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Pcrmit cxpires lEo days from
issue date
EXPRESS BUILDING PERMIT APPLICAT
TOWN OF YARMOUTH
Yarmouth Building Department
I 146 Route 28
South Yarmouth, MA 02664
(508) 398-2231 Ext. 1261
CEIVED
JAlt 0 3 2021
ENT3
ttl lZiyor s -c.A lry1od-U,L 071€ 4CONSTRUCTION ADDRESS:
AS SESSOR' S Ii{FORMATIOT.T-, :
Map Parcel
O\!\ER o rA
Nfu\tE
?-n 12.lZurr sl Mo4'{"Ao265tl ?€J,
PRESLN-T ADD SS
-33 gE
TEL #
coo,r*cror,lZ T Cons *c.(io..2 hrsa Po "l ttrroul/t 14 g 6{4
NA.\IE
d Residentlal E Commercial
Home Imp rovement Contracto r Lic. * /9 10i
Workrnan's Compensation lnsurance: (check one)a I arn the homeowner ! I am the sole proprietor
Insuraace Company Name
NIA.ILING ADDRTSS
Replacement doors: #_
IDsulation
Pool fencing
fo8- ?6o- /
9oo. oo
3E
Tent Du ratio n
..,tst. Lost ol uonstructron I /
Construction Supe isor Lic. #/,,/6
/ I have worker's Compensation Insurance
nrL Gro Worker's Como. Polic\+Ve V o{12,o 4o{
(Fire Retardant Certificate attachcd?)Wood St0ve_
Siditrg: # ofSquares 6sq-.Replacement wind ows: t I-T
Roofing: # of Squares_ ( ) Remove existing* (mar. 2 lavers)
_ Old Kings Highway/Historic Dist. ( ) Replacing like for like
Ton n o{trt otrl<^ 0,1 sa,l 4ce,e-
*The debris will be disposed ofat:(06 re-s+
(nc
6t w. /arnl 02
L tion ofFacility
I declare under penaltics of perjury that the statements herein contaifled are true and co(ect to the best of m!, knorvledge and belief I undersrand that any false ans\yer(s)
will bejust cause for dcnial or fmy license and for prosecutior under lvl.G.L. Ch 268. Se$ion I
Applicart's Signature Dare O OL
D*e O 02 eoz,O\ryoers Signrture (or aft:rchment)
Approved By
Lee .one-(rqclion 5rS e Ao*";(.C.O t'-l
Building Official (or designee)
4L ]-
E}iAIL ADDRESS
Water Rcsource Protection District
i Yes iNo
Within 100 ft. of Wetlards- Yes I No
TEL #
\\ORK TO BE PERFORT\IED
Date:
ZoniIg District:
Historical District: - Ycs I No ftooa ptuinZne : i Yes I No