HomeMy WebLinkAbout2016 Mar 01 - Sign Off Transmittal Form, Plan - Pool � � _
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s' s "�`}� HEALTH DEPARTMENT
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'''��N`` PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET
To be completed by Applicant:
Building Site Location: �Q 1J�'� �P �/�� ��l /t/�
Pro osed Improvement: /h �/?Oukc,� .�iim/'Li�tics �dd l I
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A licant: `�
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Address: /� / �,�9�< /?c� �/�'�au7`!i ��� Date Filed: �� /� I
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**If you would like e-mail notiftcation of sign off,pdease provide e-mail address: ',
Owner Name: LE'O �OV�C
Owner Address:__a0 /lfi�►�lP 1�� �� D/��ve Owner Tel. No.: '
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RESIDENTLAL AND/OR COMMERCIAL BUILDING ;
HEALTH DEPARTMENT: Determines Compliance to State and Town Regulations; i.e., Requirements f
For Septage Disposal and other Public Health Activities.
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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
(all egisting and proposed) — i
Note:Floor plans not required for decks,sheds, windows, roofing; �
(3.) If necessary, Title 5 application signed by licensed installer '
with fee. �
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REVIEWED BY: �jr I
DATE:
PLEASE NOTE
C OMMENTS/CONDITIONS:
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