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HomeMy WebLinkAbout2011 Jun 20 - Sign Off Transmittal Sheet - Pharmacy Renovation 9.�., , __�. _.��.,., . _ .__ �. �..�e� .��,.�. ...�.�-. ��_ :T.���.-.�---� �. _ _ _ _ _ _ � , ..._�:. .,�- � � , � � � � � ',����. � `,�, F o����� TOWN OF '�ARMOUTH ��'_ A µmm�� HEALTH DEPARTMENT o._�. - � . �'�'r�., ,���i�� PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET To be completed by Applicant: x 9'�.� ��1/�1 �=�/Zf�7" ' Building Site Location: T �/jl,�I�e,��/ �'�'�/��.� 77L'� � Proposed Improvement:_T , � Applicant: �!/s ��i�7�9.�G Tel.No.: SJ���/c�d3�� Address: ��t'i ���i�/ �• s- .Y�/'���'�'''� Date Filed: �• ,�A � *� **If you woudd like e-mail notification of sign o,fJ;please provide e-mail address: Owner Name: /�1��/�0� � sr�/�iqs'S LG G Owner Address: �4�� ���Si�CI�hi T/�L �� � Owner Tel.No.:7�/-9 ......�'� �:�,�.r�............../�'...�...�1 �....a...f....��./..................:..................:....:..,.................::.....................:........::. :.:...:..:..........................:.................... RESIDENTL4L AND/OR COMMERCIAL BUILDING � �:. HEALTH DEPARTMENT: Determines �ompliance to Sta.te and Town Regulations; i.e., Requirements For Septa.ge Disposal and other Public Health Activities. 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 Iabeling ALL rooms within building (all existing and proposed)— Note:Floor plans not required for decks,sheds, windaws, roofing; (3.) If necessary, Title 5 application signed by licensed installer I� with fee. REVIEWED BY: DATE: �i � PLEASE NOTE COIVIMENTS/CONDITIOAd5 �••- , ,.. , -� �� �, 1, �,� �-�T;.� 1-c i � (,Q. v.�G` -- i , � � , , , � , . � . /. F - 8-Oesc�ipdon of P Watit(d�ed�aN aPP��) � ` ' New Canstrnction ❑ t�mu��omtM�1 No.of 9 roama (Iw mutt�pM hm�r onN1 No.of eathrooms � ExhU�O� Rep�'(a) ❑ Aite�iana Additlon Q Aoceseory C� � Demotitfan Othet Speci(y: sriet oe�plion a Propoaed wcxk: � cv+�• o,:— � # � 1� ' �n�'t� � ` � , w `�t � ; I 4 � � � i • � S�iQfl 7-Uf�Q Stld�:Cf1aRJGdOit ; d ' B�uYdip Usir c3�oup 4t�dc a�) conan,dton ryp. A A38EA��Y Q Mt Q A.Z (� /�,3 O �A Q A-4 A3 4S Q 8 � O � O E EDIJCATIONAL �� Q F RACTCRY. (� f•t F$ x O H MNiM MiALiRQ (� � n / ��� � 1 INBTIfUT101�fAt (� Ft 1•Z E3 � �i i M � � .�, A RESIOENIUL. (� R-i R-Z PI-� SA �] S 91�[iAQE Q S-1 Q &2 � O U UT1U3Y Q �y, M MFXINI tJeE Q �Y' S �dI1L tl�t (� �SACti011� f'9f10Y�0/��Q[�ifld�QP k!lisf. e�w.c� _LI.1 �oo«b u„c�«,� �'l �,wq►�u+d.or�eo c�� �a►�s►�,a�,�eo ctin� S�ctbn a an0 Ma ArN (N app�l Mn�bv d Noa�a�wrN� ' h+eY+d�QM�n�wrf IrwY F1oar MMlpw floar hR Tom1 Ara AN Ftoas i� TMaI (t!} s.ca�n s-s�ucTu,�t p�ER�t�w �oc���a�t �nd�pwtdMnt 9NruCMItM B�yY�Mirg'3bt�GR�fi1 PN►AlYIrMr Riquind YM.......... No. SEC?lON i�QWNEA AUTHOpfZA'flON•10 8E COMPf.ETED WHEN O ER'3 A[3ENT R C�NTRA�TOR/1PP1.lE9 ft7R BUiLOitVt3 PEFlMI'f _ __--- _ ��._ _ __ -- - --- .:.---_ _ --__----__ _----:as�rrnerof-the . r �s�rblact propert'yt--__ _ _ hereby�thoriz� � C'" to act on rrry .in aM ma�ters rela�w ta wo�1c au ed by thfs buiiding pem+�applkatbn. � � d OwnN Dat� ' id � OVER