2021 Sign Off Transmittal - Replace Chimney � R
�.o�:Y TOWN OF YARMOUTH
44 °; HEALTH DEPARTMENT
PERMIT APPLICATION SIGN Q TRANSMITTAL SHEET
To he completed by Applicant: I O pelf-J-1 r G v1,
Building Site Location:
Proposed Improvement: e; . r f /�` ( r_y-
Applicant: ,�.4 y j ut,'I Tel. No.:
Address: t f' ?ecCl;i d 1Dr - Date Filed:_ 5 ? ) i
0-**Ifyou would like e-mail notification of sign off please provid e-mail address: --) %} (' Yit: Vt \ 1
lt
Owner Name: �>'� \ . Uh \
Owner Address: I C cC\..,V Owner Tel. No.:('17!- ) .%e?lc) 1
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: '177,/'
/ DATE: V
PLEASE NOTE
COMMENTS/CONDITIONS: