HomeMy WebLinkAbout2021 Sign off Transmittal - Use & Occupancy Jt-Yah
TOWN OFYA TOWN O;:t; %)4*
HEALTH DEPARTMENT Sip C ZOZ1
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PERMIT APPLICATION SIGN OFF TRANSMITTAL T,
To he completed by Applicant:
Building Site Location: 33
Proposed Improvement: - r C> C C c,— SZ-1-�� ( W--
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Applicant: TCtIliCk TTU e CUI .a N j V Q Tel. No.: 1 ' -02- 5-3
Address: l . u /M g Date Filed:
**/f you would like e-mail notification of sign off please provide e-mail address:
Owner Name: t 1\-i J`1 ` C� Lie CI_(abd`
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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.
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: �� u, DATE: i' 9/2-
PLEASE
NOTE
COMMENTS/CONDITIONS:
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