HEALTH SIGN OFF TOWN OF YARMOUTH
a ,�- ,� o HEALTH DEPARTMENT
PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET
To be completed by Applicant:
Building Site Location: /e„ /- Dh ii-v
Proposed Improvement: Hove t r ,o r u) i/ 'r
p , P A 1` + !// r ( �cllJ�O1�OX �u f JI h r� q/
CA.' oav roo, aPi G A e /o5e I
Applicant: a ion tf,3'e0 71 Tel. No.: 77t/ a /2 - 0191
Address: 7I c
Date Filed:
**lf you would like e-mail notification of sign off,please provide e-mail address:
Owner Name; :/?awr+ &fn _
Owner Address: tY1 f 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,
KC ,Eni! and septic system location;
(2.) Floor plan labeling ALL rooms within building
JAN 1 8 2023 (all existing and proposed) —
HEALTH DEPT 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:
PLEASE NOTE
COMMENTS/CONDITIONS: