HomeMy WebLinkAbout2022 Sign off Transmittal - Pergola TOWN OF YARMOUTH
HEALTH DEPARTMENT
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PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET
To he completed by Applicant.
Building Site Location: PU42'45 44/1-- (' va
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rProposed Improvement: .,teq t \' / G >( 6.00
Applicant: 00") /1) r7-e 2 Tel. No.: -5"..e,
Address: -e Date Filed: fc" 2Z—
"Ifyou would like e-mail notification of sign off please provide e-mail address:
Owner Name: 4.421 L
Owner Address: i-"Li P e.ay.e Owner Tel. No.: / —4-it 3 53 I 4(4/7 RESIDENTIAL AND/OR 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: (./ DATE:
PL ASE NOTE
COMMENTS/CONDITIONS:
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LOT NO. : 9 ADDRESS :_ 1¢ P yrif uq-- CO0i c,,Pc(E
OWNERS NAME : fD�u/y LL\c c.Aert'fiV
SEWAGE PERMIT NO. : ,'f-/93 NEW : t/ REPAIR:
DATE ISSUED : 5- 7- DATE INSTALLED : q- 2-7-1 q
INSTALLERS NAME : Pae 14,A) G , 1isS(i,x1 c
ia 'x yv 'X 1 '
INSTALLATION OF : /st,y csr p hose S Fie,.Joir osci -
WATER TABLE : ' C FINAL INSPECTION BY : 64;k4
DRAWING OF INSTALLATION ON REVERSE SIDE :