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HomeMy WebLinkAbout2011 May 16 - Sign Off Transmittal FormoY:YAk TOWN OF YARMOUTH 1 HEALTH DEPARTMENT PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET To be completed by Applicant: Building Site Location: ' ©'� q3 �� �" ` j� v '--)'1^ h �T Proposed Improvement: US e t o CC o P A N C y -- P 6 j ?L Applicant: U _Q4 y Tel. No.: 9 7L �10 - S 7 3 7 Address: 10 5 e-X(v1.4�F LA E tam 01 �'�� Date Filed: **Ifyou would like e-mail notificationrofsign off, please provide e-mail address: )�^�`� Owner Name: Y'� � S O `•1 r 4� I- � ' F1 R Owner Tel. No.: Owner Address: 1 5 i� V4 S J �^ 4 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: PLEASE NOTE COMMENTS/CONDITIONS: DATE: �� (^(.,4e I fijo G� /