HomeMy WebLinkAboutTransmittal Sheet 01-18-2019 Petinli Nvo7 /LWqu/
,0 mY ,. FoeC1r4PE7 Is-16 TOWN OF YARM •
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�; I Q� HEALTH DEPART t NTAN i 2019
scar" PERMIT APPLICATION SIGN OFF T' ' InbiA�,"g
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To be completed by Applicant: /,
Building Site Location: / e�II1 �vG 10< /4/1otq.
Proposed Im rovement: A- (/; w- t/o /grog, JOQ7, 4�T4
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Applicant: 7/# 57iVW'
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Address: /1/fie�r� //'? bregfif fillit6V Date Filed: SW
"If you would like e-mail notification
'of'sign off please provide e-mail address: CC,e1051.ra t9, t/nn/C , (,t7el
Owner Name: Tir Jn`'
Owner Address: (/75.^10741 b ' 419 41 Tel. No.: roprn
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 existing and proposed)—
• Note:Floor plans not required for decks,sheds, windows,roofing;
(3.) If necessary, Title 5 application signed by licensed installer
with fee.
REVIEWED BY: !g 4 DATE: /he // _
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PLEASE NOTE
COMMENTS/CONDITIONS: