HomeMy WebLinkAbout2013 Jan 22 - Sign Off Transmittal SheetoY TOWN OF YARMOUTH
3r HEALTH DEPARTMENT
PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET
To be completed by Applicant: 1
Building Site Location: % �; �/" y�� !� 1//1'y"�1�1�1 �A l �i �(3' }T14—1 �1�%�'Ii,� f a, —
Proposed Improvement: % (24�)
Applicant: 441,]11(1 � � � �t` �&C
Address: �ti i2Date Filed:���� �-� 3
**If you would like e-mail notification of sign off, please provide e-mail address:
Owner Name: /
Owner Address: �,' ('��,1 �� '� , � l' 1% Pf �'C ��% �2.(��'��� Owner Tel. No.:,P)(nJ �'� ')o
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:
(L) 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:
COMMENTS/CONDITIONS :
PLEASE NOTE
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DATE: I -- '" r ?