HomeMy WebLinkAbout2009 Jun 19 - Sign Off Transmittal Sheet, Floor Plans. Vision Info - Bathroom i � ;,���-����-;�-. ,-m �,,.���, �.-T�.-�-�;-���
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�•°�.Y`��o T(�� OF YARI'VIQU'TH .
� y H�A�.;T�I DEFARTMENT
� �� MAriA M��(�S .'l' � . . . . . . ;.. .: . .. :�. �:. .. . . . . �.� � i
. ��ISOAp�,r� � .. .�. P�gMTT APPI,�CATION S�GN UFF TRANSMITTAI:.SHEET���� � �� . I
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To be completed by Applicant:
Building Site Location: Z.: � t'�1 ���p No.: Lot No.:
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Proposed Improvement: �'�`k}-�� E!) � "7
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;
� � �� 3 , i�. ��Sl�'
;
Pp �� Tel. No.: .�Q�'S""��Z' {��7t�
Address��. fit� (..C. .frtj .$( l�h��� 1 �i�-� ���'�" Date Filed:_�' ��j
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**Ifyou would like e-mail notification ofsign o,fJ;please provide e-mail address: I��(... ����(�'' � ��� j���
Owner Name: ���• !� , ���"
, Owner Address�Z ��'�� ..�T� fi�1 ��� /'�wner Tel. Na:�0�„1�" 6 �'��t.�'
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RESIDENTIAL AND/OR COMMERCTAI.BUILDING
HEALTH DEPARTMENT: Determines Compliance to State and Town Regulations; i:e., Requireinents
For Septage Disposal and other Public Hea.lth Activities.
Please submit four(4) copies of plans, to include:
(1.) Site Plan showing ea�isting buiidings, water line locatian,
and septic system location;
(Z.) Floor plan labeling ALL rooms within building
(all ezistiag and proposed)—
Note:Floor plans not required for decks, sheds, windows, roo,fing;
(3.) If necessary, Title 5 application signed by licensed installer
with fee.
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REVIEWED BY: DATE: `7-
PLEASE NOTE
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