Transmittal o, -Y-F- 4ii.,� TOWN OF YARMOUTH
[' HEALTH DEPARTMENT
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PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET
To be completed by Applicant:
Building Site Location: 2 C\10,r\c el Q O\c1 N )i-- i W eSk '1 c A rn o U1
Proposed Improvement: 70 v\saki ok \lv,X 1,12 t.mt:ke. s.%rek en rnq i Oa w— ASTM
v`Wb t-tt awk-ppncA C `,-,0.cC..i cov'€r cula a 'ir1Ifir4) CA. al Y 61/ '$ ,n.i-e .c .
Applicant: CUS\-Orn ( ua1, FOOtS _ Tel. No.: c 1t - C (rj .1 - is'a Cf 0
Address: (0 1 Y\+1.kS b C j `i\\eCi CGt /IAA U `t a\ Date Filed: L 1 1 3/ a•
**If you would like e-mail notification of sign off please provide e-mail address: J e i\i1X. 1.--A Cus 4o Mi Uii) / P o o c •C o:Yl
Owner Name: 1 Ckv S ‘M mo c%s'
Owner Address: 'I Cna c R2\ 4O k elk Dc V, IckcrncA MA 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:
MED (1.) Site Plan showing existing buildings, water line location,
RECE
and septic system location;
JUN 1 ` 20?? (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: ., rJA-,-2.�o DATE: 7-- it-
Z
PLEASE NOTE
COMMENTS/CONDITIONS: