HomeMy WebLinkAbout2006 Dec 22 - Sign Off Transmittal Sheet, As-Built - Deck, Sun Room r , , �
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�.��'Y`�.� � ` ` 'TC1WN OFf YARMOUTH
� � c HEALTH DEPARTMENT �
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� MATTA N 5 � . . . �
�"��°��� PERNIIT A�PLICATION SIGN OFF TRANSMITTAL SHEET
To be completed by Applicant:
Buildin Site Location: 'i 1 �r7 ��'�4 U`U/}- � fl Map No.: (�3 Lot No.: S�U
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Proposed Impravement: � f c n �r� � 1 �'' �'� � � � � '"
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Applicant:� r �7��2�G� � ,' �� Tel. No.:
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Address: `� f r�� � � ►n< Date Filed: J,�? o?� ��
**Ifyou would like e-mail notification ofsegn ofJ;please provide e-mail address:
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Owner Name:�� �'i t- �"� lI Y� ��.C t� �� !'�U,� �0�
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Owner Address: �. n /-�� 'f t�i'�t Owner Tel.No.:(.,l 7� y J,�� �'I 7GJ
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RESIDEIVTIAL ANDIOR CUMMERCIAL BUILDING
HEALTH DEPARTMENT: Determines Compliance to State astd Town Regulations; i.e.,Requi�ements
For Septage Disposal and other Public Health Activities.
Please submit four (4) cop�es of plans, to include:
(1.) Sit�e Plan showing ea�isting huildings,water line location,
and septic system location;
(2.) Floor plan l�beling ALL rooms within building
(all ezisting and proposed)—
Note: Floor plans not requined for dec�is, sheds,win�iirws, reofing;
` (3.) If necessary, Title 5 application signed by licensed installer
with fee.
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REVIEWED BY: ,.DATE: I � I �-�-�� �`
PLEASE NOTE
CONIlVIENTS/CONDITIONS: � �'r � ��� �C,.,, �-..i ..,,,_,.,
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; MAP NO. �3 � ��
; LOT N0. : A.DDRESS: S� ���1����' ��
_ ; UI,TNERS NAAtE: �i'i�'7-����'•J' :
SEWAGE PERMIT N0. : �'�"����NEW: REFAIR: �
DATE ISSUEll:' �r'�p"�D�TE IPISTALLED: ��'"�'"��
' Li]STALLERS NAME: �'%�a ��'`�'��`�'�
, �� 3,f d Ti�h✓�rav-7/� �i1�.4�+r.6d'��
INSTALLATIOM OF: '�'��'�' ��'�`"��� �'"jG"�•
WATER TABLE: � � FINAL INSPECTIOI� BY:�'�� �_
i DKAWING OF IIVSTALLA i I�1N ON REVERSE S IDE :
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