HomeMy WebLinkAboutImage_003.pdf - BLDX-24-104 36657Office Use Only
lPermit expires 180 days ftom
issue date
CONSTRUCTION ADDRESS
ASSESSOR'S lNf OruvhTlON
EXPRESS BUILDING PERMIT APPLICATION
TOWN OF YARMOUTH
Yarmouth Building Department
1 146 Route 28
South Yarmouth, \.[A 02664
(508) 398-223 I Ext. 1261
Map Parcel
OWN*ER: ../'.OV/gT I ,1-2lz
RECEIV
JAN 3 0 202{
ING DEPARTMFNT
D
8y
--
Nfu\IE PRESLN-T ADDRESS TEL. i
CONTRACTOR 9-N.{\IE I,L,\ILING ADDRESS
D Residential I Commercial Est. Cosr ofConstructioo $a0
Holh€ Improv€m€nt Contractor Lic. #eQ-f l7 2 3 Conslruction supervtsor Lic- * _4-435,34_/oo
Workman s Compensation hsurance: (check one)
J I am the homeowner a Iamrhesole proprieror f have Worker,s Compensation Insurance
Tc[t _
Insurance Company Name ,hrz{llfz,worke.'s Comp. Policy#
\\'ORK TOB E PERFOR\IED
Duration (Fire Retardant Certilicate attached?)
Siding: # ofSquares Replacement windows: #
Roofing: # of Squares 3 ( ) Remoye existing* (max.2 layers)
_ Old Kings Highway/Historic Dist. ( ) Replacing like for like Pool fencins
rThc dcbris will be disposed or'at
I declarc under peoalties of pedury., that the statements herein
Location ofFaciliry-
contained ate true and conec! to fte best ofmr knowledge and belief l understand that any false ansNerc)
Date
Dete:
Date
Flood Plain Zone: - yes: No
Within 100 ft. of Wetlands.- Yes I No
will bejust cause for denial or n ofmv license and for prosecution under lvl.G L. Ch. 268, Section I
Applicant's Signature
Owuers Sig,lature (or attachm
(or designee)ENLAIL ADDRESS
Zonirlg District
Historical District: i yes I No
Approved By
Building
Water Resource Protection District! Yes aNo
/"r c i n c tlrD Ynhoj'^
Wood Stove--
Replacemerlt doors: #_
Insulation