HomeMy WebLinkAbout2008 Jun 13 - Sign Off Transmittal Sheet - Use & Occupancy, New Owner �_ _
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,�°� Y��o TOWN OF Yt�RMOUTH
n _ y HEALTH DEPART�VIENT
H��ri� � « �
�����a�C� PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET � �
To be completed by Appdicant:
Building Site Location: �R�� � �-£� Lv.a�� \�(�,.,�rK�v►t-t Map No.: Lot No.:
Proposed Improvement: � Q j,U ��j'
Applicant: l:.L-t�SS�G1�(... �7� �� � �R-Z...w S Tel. No.: '�D�S ��71 SfC7 Z
Address: �,P J1 � � t.�,}t�,s�" `.t(���np,�-1 �� Date Filed:
**If you would like e-mail notifccation of sign off,please provide e-mail address,-
Owner Name: �v'�S"t"OP�t�� U Y�.+MGs..�fti
Owner Address: � `�i���'��R WCu„� Owner T . o.: � �-��
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RESIDENTIAL AND/OR COMMERCIAL BUILDING
HEALTH DEPARTMENT: Determines Compliance to State and Town Regulations; i.e., Requirements
For Septage Disposal and other Public Health Activities.
Flease submit four(4) copies of plans, to include:
(1.) Site Plan shovving ezisting buildings, water line location,
and septic system location;
(2.) Floor plan labeling ALL rooms within building
(all ezisting and proposed)-
'� N�ote:Floor plans not required for decks, sheds, windows, rooftng; '
(3.) I�necessary, Title 5 appl�cation signed by licensed installer j
C with fee. �
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REVIEWED BY: ' � {./�� DATE: �D ���DrcT
PLEASE NOTE
CONIlVIE S/ ONDI IONS-: f _...�. f - .
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