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TOWN OF YARMOUTH
HE-.PvI I`EI L_)E.E'T �
HEALTH DEPARTMENT6.4
PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET
To be completed by Applicant:
Building Site Location: 16- e n -e.r b 0&rL L&n So cu1/4 m o J
Proposed Improvement: rri S4- j 1 4,-h&y- OP (sir cS wb mrni, j°c'° /.
Applicant: E,LA I" DO L S Tel.No.: 50 8-- 3 4 S- 21'
Address: �j `� l/C)l�l }e$ e t ` S. G ✓rt 60tt•-- Date Filed: q--),3- ba-a
VV - O &G (oLi
**If you would like e-mail notification of sign off,please provide e-mail address:
Owner Name: C) 6 y i b A -H U N
Owner Address: LP I Wilt t (,L,mSb0-4 (-b Owner Tel.No.: S
n.eLiN-1 I(33q
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: DATE: 3
PLEASE NOTE
COMMENTS/CONDITIONS: