HomeMy WebLinkAbout2016 Jul 09 - COTTAGE - Sign Off Transmittal, Floor Plans - Converting Dining Room to 2nd BR C011 &
TOWN OF YARMOUTH
• c HEALTH DEPARTMENT
•• PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET
To be completed by Applicant: d G •
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Building Site Location: /5 A e(-� arc CC`l • Le). )/AlrrY)0 1 Y1 oSS.
6-13
Proposed Improvement:Pha{i i h oul I (L�C / roc)Yy� (. O O Sr �m
ApplicantDP40 ICI 4 /jndi Tel. No.: caY - 775---0J-5-7
Address: / I cdS d ec I Ct.) . JALrmOL) /lass Date Filed: -7,—/b-Li ?Joy ?
**lfyou would like e-mail notification of sign off please provide e-mail address:
Owner Name: Jiek1r) ,' n Cid S&rc- ?o
Owner Address: 3)9-f1 F /4 5 t ( A-L .0 YC Owner Tel. No.:
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: 2 DATE: 7-- c'/"— 16
PLEASE NOTE
COMMENTS/CONDITIONS:
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
al - Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
i1 15 Bradford Rd West Yarmouth, MA
PnVertY Address Denise Sullivan 181 Thacher Rd
Owner Owner's Name Milton MA 02186 4/30/2011
information is
required for
City/Town Stats Zip Code Data of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system,including ties to
at least permanent anent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building.Check one of the boxes below:
(e hand-sketch in the area below
0 drawing attached separately
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