HomeMy WebLinkAbout2022 Sign off Transmittal ��t Yak TOWN OF YARMOUTH
;-*41A,° HEALTH DEPARTMENT
''�• `' PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET
To he compleied by Applicant:
Building Site Location: .0 —1-61/4-,-)v\ Am) ) S g x(1146 4,11J �Proposed Improvement: `�cn,t: k kx.,d B1/4,tttAtpnot.
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Applicant: :7C)�vl 1—�f e v, U('\ Tel. No.: S -3 Qe �l GL3
Address: `2j(:) -1-6—LAA 144 Ave . 5 7GV 4o4) MA, OZ bate Filed: 61 ZIZL
**/fyou would like e-mail notification of sign off, please provide e-mail address: J 6C'\vi��eh W �b+��GS�, n
Owner Name: (AJ1 d
Owner Address: 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.
RECEIVED Please submit three (3) copies of plans, to include:
(1.) Site Plan showing existing buildings, water line location,
MAY and septic system location;
(2.) Floor plan labeling ALL rooms within building
HEALTH DEPT (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: 1,
PLEASE NOTE
COMMENTS/CONDITIONS: •
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RECEWED
MAY 2 0.2022 o----Lt
HEALTH DEPT. 111.1 1 i /1/1/1 61 G�
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OWNERS NAME : pk_ if / a l 0
SEWAGE PERMIT NO . : 1�S NEW : REPAIR:
DATE ISSUED : 30'DD TE INSTALLED :
INSTALLERS .NAME : �'j.,+.. c• p X,t/A-3 o ''-'
INSTALLATION OF
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WATER TABLE :0FINALr imEgRosii BY :
DRAWING OF INSTALLATION ON REVERSE SIDE :
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