HomeMy WebLinkAbout2016 Jul 11 - Sign Off Transmittal Form - Use & Occupancy ,..�.. �m__ � _.m t�. _.�_� . , _ _ �_r�� ��,F� _ _ -�.,.�� _
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.o�-'Y�� TOWN OF YARMOUTH
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�; �'- ° HEALTH DEPARTMENT
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���'���,.�.-N�`'�l� PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET
To be completed by Applicant:
Building Site Location: �3 ���� r-� �A'� S� 6�� � � �/
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Proposed Improvement: (���-s.. c� b(;('���C G/ � (���C 1��G��`
Applicant�� � � ��.a�'/�S ` �. �� I�. G�t�� Tel. No.:S�-�`l��9�� i
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Address: �3 1�-��'�� `��`�- J ��`U S� `�,�rC'rr''r;��'� �L� ����Date Filed: ��' � � `��'
**If you would like e-mail notifrcation of sign of�;'please provide e-mail address:
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Owner Name: � -{�-'�'f'T � l�t--1!�
Owner Addxess: � I.aPC'fi ,n,d�.,�7� � Owner Tel. No.:��D-7��'�SQ �
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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. '
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 labeling ALL rooms within building
(all egisting and proposed) —
Note:Floor plans not required for decks, sheds, windows, roofing;
(3.) If necessary, Title 5 application signed by licensed installer
with fee.
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REVIEWED BY: V DATE: �� � �� � �''
PLEASE NOTE
COMMENTS/CONDITIONS: �( � �G
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