HomeMy WebLinkAbout2019 May 01 - Sign Off Transmittal, Plans - 3 Season Room . o t ,,0lea TOWN OF YARMOUTH
s; c HEALTH DEPARTMENT
--• PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET
To be completed by Applicant: Et t-cem STET
Building Site Location: J r�
Proposed Improvement: / j /6; /Q4-' -4r=`k"4' X2-4-- /_ u,` ,,Sc„,, awry
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Applicant: 5,04 .01a it ' e.e.ove. ► �..a' ez, Tel. No. � ._lid (.' ‘'5'
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Address: ;��`'. Fl��'r?�.,.> ,
' i -- I Date Piled:
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**lfyou would like e-mail notification ofsign off please provide e-mail address: 1
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Owner Name: -'1f-I/4 -4-L. it r�,,,i t--(c? C I 'E.5 6-2
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Owner Address: F r`� ...�/�4//0 6 671- Owner Tel. No.:
RESIDENTIAL AND/OR COMMERCIAL BUILDING
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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 G I
(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: DATE: �'- / Cr
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PLEASE NOTE
COMMENTS/CONDITIONS:
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: • :MAY••012019. • ► . . . # 183 - • ' -
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HEALTH DEPT:. • 143 8 G° • r
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Title 6 Official Inspection Form
r - 'fir, - ,-, submit**swp,Disposal System Form-Not for Vokintari MN:38MNit!
183 Elkus'Street •
. Pm:arty Addams
Moly Plaster
Owner Owner%Nana -
information is .
sawirad for Yaneouthpat MA . • 02875 03/29/10
(NM Peg& City/Tovar- . Nate. Zip Cods Date af inopaotion .
D.System Information (cont)
Sketch Of Sewage Dispose Syetent Provide a sketch of the sewage disposal system hicluding ties
to at least heopennanentieference haxlmaiks or benehmailcs.Locate all'Wale within 100 feet.
Locate where public water supply antes the beleng.
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