HomeMy WebLinkAbout2011 Aug 28 - Sign Off Transmittal Sheet � � .. _______ __ _
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' ot R�,� TOWN OF YARMOUTH ;
o� ° HEALTH DEPARTMENT I
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����%'��x PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET
To be completed by Applicant: �
Building Site Location. - � � �;i�u-! � � .`_. �U- / � ;'%�a 1�t ;� �_N�,�u:��f r"vl TZ ���/
' Proposed Improvement: 1�(� �M � �n u� � v_ ' � z`� `-- '''�� �r 4/"J — I
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`� � Tel.No.: 5�d'-�6/- �y�'
Applicant: 1= '���/ �� V� �Z� -�/ � � �I
Address: �� 7�•_�r f�c �°.�l r�` Gi r c�£ � �S ��°�, .P.-�,*� 0.2G�f� Date Filed:!���Z S�ZO// �
**Ifyou would like e-mail notifrcation ofsign off,please pravide e-mail address: i
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Owner Name: �� {�� �� � t�.�-, ( � '� � �-2•�/ �
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Owner Address: �`. / �,�_,f � � 2 f� Y �+a" � � ,��-v�'-: ��� s�-�110wner Tel. No.: `_7ti-�(/-/�/f'� I
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� RESIDENTIAL AND/OR COMMERCIAL BUILDING
HEALTH DEPARTMENT: Determines Compliance to State and Town Regulations; i.e., Requirements I
( For Septage Disposal and other Public Health Activities.
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f Please submit three (3) copies of plans, to include:
(1.) Site Plan showing existing buildings, water line location,
and septic system location; '
� (2.) Floor plan labeling ALL rooms within building 'i
� (all existing and proposed) —
' Note:Floor plans not required for decks,sheds, windows, roofang;
� (3.) If necessary, Title 5 application signed by licensed installer I
with fee.
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REVIEWEDBY: DATE:�/���/
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PLEASE NOTE
COMMENTS/CONDITIONS: � J
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