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'Y'lh TOWN OF YARMOUTH CtA,�
s0 . 1t.„,° HEALTH DEPARTMENT �t i�v
4C�c" PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET
To be completed by Applicant: i
Building Site Location: 31 lo CR u, a `�% �'^"u ^ i M, Y
Proposed Improvement: �v�_ 5 r e \ oC,. r-
7'H ( l2..7 5 Lc( .
Applicant: ( k ,), 1 s V. -t' Tel. No.: Sa q `11 tb" 70 4 0
Address: `? 1 C�, l t l c-*'` 0,A n eN . \1-.0""42 Date Filed: i k3 I 111 1
**If you would like e-mail notification of sign off please provide e-mail address:
Owner Name: 6 '4111$\ G C,- cl- ,n-- u t-'•
Owner Address: \ 0 6 0)/ \ \D cJ Owner Tel. No.: 5-O -d S L) -34,1 y
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.
7
REVIEWED BY: DATE: / O (7 / a
PLEASE NOTE
COMMENTS/CONDITIONS:
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