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Home My WebLink About2012 Jul 24 - Sign Off Transmittal Sheet - Use & Occupancy .-� ., �� -��-.�,Fl.� �.n , ��:�..�.s--.�-_-� — � --- . . _ � - �,:. �-�� -� . : v o,.�':..� TUWN t7� YARIV�OUTH � ��„" `',`+' �� -� �s�� HEALTH DEPARTM�NT — .r � "`',�M�`•` ' PEitMIT APPLICt�TION SIG�T OFF TRANSMITTAL SHEET � To be cnmpleted by Applicant: Building Site Location: �31� �D G/l� � d ��t2 i4tC�lJ 7h�1 l�D 127'� 1�� Q�.G"7 s i Propos�ci Improvement: USE � OCc.J��4 N�� - �X f��!N C� l�=�T��7 t.,,. $ �'U!'L� ApPlicant: U J��Tb 2 Z t/K A�t S� Tel.No:: 774�Q�7-X:!o�9 Address: / � SI�IA tl..�2 l-k3�S� leJ�. Date Fiied: 7'Z� ' /2 **If you would dike e-mail not�cation of sign o�'pdease provide e-mail�ddress: Owner Name: '�.tll�f��' M d/1 U,v f2.L---?�;C T Y fiQ.0 S T � V I tC Tb 2 2vl��.� 1�,,+�.3': T'12,uc S 7�f Owner Adc�ess: 3 3 D IZt7 J � �"a /� Own;er Tel.No.• S�� 3C Z '-2 q t,r� . ;_....:.: y.��v.rN Pv/L'� M./� . O �.6 7 S - : ......... ...... ......... ....�.. .... ......... .. ..... ............ . .......... ... . , . .. .. ....... .... . .....�.. . .......... ...... ......... ... ...::....... ' RE5�D►EIKTIAL AND/QR+Ct�►A91VI�ItCIAL�IJILDrING • - HEA�,TH DEPARTMENT: Determin�s Compliance to Sfiate and Tovvn Regula�ions; i.e.,`Require�nents For Septage Disposal anc�other Public Health Activities. Pleas� submit t�ree(3).�opies of p�t�ns, to in�h�de:. : . (l.) Site Pla�t showi�g existing buildings, wate�lide.l��e, �nd septii� syste��iucation; (�.) Flo+or pl�� I��ng A.,�L�,, rooms wi��in b��ld�ng (all e�istiag and propo�ed)— Notet,�'four plans not re�►uireaC for decks,sheds, winde�s, rcro.Jf�rg;" (3.) If necessary, T'itle 5 app�iea#ian signed by li�e�sed instatler with fee. REVIE�ED BY: DATE: �`�� °: PLEAS�NOTE COMI�IENTS/CONDITIONS: "