HomeMy WebLinkAbout2015 Jun 08 - Sign Off Transmittal Sheet, As-Built Sketch - Three Season Room/Kitchen Remodel oF�q�r,y TOWN OF YARI,VIOUTH
� =�O HEALTH DEPARTMENT
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� ''��_••`� � PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET
To be completed by Applicant:
Building Site Location: � S N 0�� M��� S�
Proposed Improvement: ��'{ ��C�y� '�"�{� ��y �� � �11��� ��t���
(L_SOi.�'�'j])�-5
Applicant: �V� ������ Te1.No.: 11 �'���'�S�
Address: 7Z �-IU�-L �w �h DateFiled:�p�,Z
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**Ijyou wouldlike e-mail not�cation ofsign o,�;please pravide e-mail address: `�V�T�E'�W��� ,�.(� �1��
OwnerName:�1�1M�`�j G.�Q�
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Owner Address: 1 J� ���"� ��l�Srt Owner Tel.No.: ��q��'7.7c-t'J
RESIDENTIAL AND/OR COMMERCIAL BUILDING
HEALTH DEPARTMENT: �etermines Compliance to State and Town Regulations; i.e.,Requirements
For Septage Disposai and other Public Health Activities.
Please submit three (3) copies of plans, to include:
(1.� Site p�l�tn showing existing buildings,water line location,
and septic system location; �
(2.) Floox plan labeling ALL rooms within building ji
'-. (all 0xisting and proposedY— !
Note:F7oocplans not required jor decks,sheds, windows, roofing; I
(3.) ` If necessary, Title 5 application signed by licensed installer '
witly f�e. _ ' i
....__..._......_......._.............._............._..........._.................... _.............................................................................::....................................................................................................................._........................................_.....
REVIEWED BY:�1/�l ' ' DATE: G/� /,�
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PLEASE NOTE
COMMENTS/ ONDITIONS: ' -
Sc.�r•T New S-� �� Lu�4 .`�1v�.� � � [AC 3 �' � Tr� �2io✓C 7'(1 p- P.
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� � Commornvealth of Massachusetts - —
-' Title 5�Official lnspection Form _
Subsuriaee Sewaye Dfsposal System fortn-Not for Voluntary Assessments
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D. System Information (cont.)
Sketch Of Sewage Disposal System:Provide a view of the sewage disposal system, includin9 ties ta
at least Nero permanent reference landmarlcs or benchmarks. Locate a�F weris with� 700 feet. Lxate
where public water supply enters the buiiding. Check one�the boxes below:
❑ hand-sketeh in the ar�below
❑ drewmg atfached seP�Y
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