HomeMy WebLinkAbout2019 Oct 24 - Sign Off Transmittal, As-Built Sketch - Enclosed Porch kr
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.Me`'ti PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET
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Applicant: --�.C,` "'
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**If you would like e-mail notification of sign off please provide e-mail address:
Owner Name: -E..A wcLA.L. t'J&
Owner Address: 4 q,, --0,Am iy:..., vc,,-- ,,ut,r V(v.,civsz, Q-A k. Owner Tel. No.: 'V1u-1(,,,'2> -(Vi ci
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,roofng;
(3.) If necessary, Title 5 application signed by licensed installer
with fee.
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REVIEWED BY: Pl- 'f `` DATE: /C3 cam. l/9
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PLEASE NOTE
COMMENTS/CONDITIONS:
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CA,+e 1 V fr 1,1 ` `.i, + r` .s,,• . ' 401 4/
Commonwealth of Massachusetts
Title 5 Official Inspection Form
r>+ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
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Property Address
(Zeit/tat/1G/
owner OH ner's Name
Information 6VeS-4—, ,e4/1449(4required for every 14 /4 00162Cily/TownState Zip Code Date of Ins n
D. System Information (cont)
Sketch Of Sewage Disposal System: Proii de a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where pu star supply enters the building. Check one of the boxes below
hand-sketch in the area below
❑ drawing attached separately
RECELED
OCT 242019
HEALTH DEPT.
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