2015 Nov 16 - Sign Off Transmittal Sheet - Demo ����
�,oF���e,� TOWN OF YARMOUTH
4� � ����� HEALTH DEPARTMENT
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� �-4+��ACNE1r�✓�' . pERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET '
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To be completed by�lpplicant: �
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Building Site Location: -- ��Z. v
Proposed Improvement:
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Applicant: L 1�, Tel.No.: �(�
Address: ( U Date Filed:
**If you would like e-mail notification of sign o,fJ;please provide e-mail address: '' �j.A�
Owner Name: �6.�1���'i� �✓l�^'S �
Owner Address: , Owner Te1.No.: �j,�
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RESIDENTIAL AND/OR COMMERCIAL BUILDING
HEALTH DEPARTMENT: Determines Compliance to Sta.te and Town Regulations; i.e., Requirements
For Septage 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 plaa iabeli�A��, xoomsMwithin building
(all existing and proposed) — - -
Note:Floor plans not required for decks,sheds, windows, rooftng;
(3.) If necessary, Title 5 application signed by licen�ed installer
with fee. .,
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REVIEWED BY: ATE: // f 6 '�
PLEASE NOTE
COMMENTS/CONDITIONS: / �'`
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