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TOWN OF YARMOUTH
--' r 1 c•' HEALTH DEPARTMENT
ort ., �� ... .3
•" MATTA N S ,
PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET
To be completed by Applicant: ,G I&/'1 }�,Building Site Location: `/' /l4Mf .1.e • Map No.: Lot No.:
Proposed Improvement: /1 7 ' ,e60114 710 .be a SLG &A a f')
/eel€ £40/2/
Applicant: oh,' Tel. No.: '60
Address: /17 /ltd iih Xyt ,pkt be Date Filed: .3/ %7
**If you would like e-mail notification of sign off,please provide e-mail address:
Owner Name: j /21'MJ dMd.. lif,C -
Owner Address: // ti0 i1/1 1 i 4f Owner Tel: No.:--2).(- '34,9
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 four(4) 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:190 ail 46Q DATE: 3 '' /7---d 7
PLEASE NOTE
COMIVIENTS/CONDITIONS:
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