HomeMy WebLinkAboutBLD-22-003806 water sign off Y ,
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( WATER DEPARTMENT
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BUILDING PERMIT APPLICATION FOR
\VA"i'ER DEPARTMENT SIGN OFF 0 - loret )(1`T
E'RANSMITl AL FORM
I3t1ILl)ING SITE LOCATION: 21'7Pj t!-Q. ...Ss4tefr
PROPOSND WORK: Akto . _iA ey-,`,f-; L .e rkii c
API LICANT:Ij-jr Qcy�- KC _.._...
AI)i)ltE_SS: l(cp( C. Oc-l-ekIAS R( .... rttiAer— AAA- 0 ,63(
TEEN IONE: 7C4, 7 (-{SOS Yo ,l--f c_ ,4(AAA-(l,.C 0 lA---
RESIDENTIAL AND OR COMMERCIAL IAI. BUILDING
iLDINCi
\, ,;;,4r 1),:pa nwnt: 1)derinincs Compliance of\V-atrr.Avail;ihilith and of existing location
i n nnccrinss Department; I);otennwo>Coniolianwe for Pat knit!wit! I)ta u,t2c
( oriscrC,tinni Coinmission. I)cterminc>Coinpliamce to\V"ctiands Act:i.c. I Iutts)border any tyI1e of
,Acttands.'[reams,ponds,rivers,occ<at.hogs,boys, marshland.ETC .
Ilealtlt Department: I)ctcrniiries Compliancy_to Stag:told I'no it Rc ulatirl;:. i.c,
ret.piircol nts Iur S::ptage I)ispo:ui and other Public I ie;tl.h \ctit he
i irc I)cp;ulntent: I)otermincs Compliance to Sinte nod Town Itequiremcnts for Perasowd
Solt . Property Projections, i.e_Stnnkc lklecturs.Sprinkler Systenh.elc
(./(pittutA 4 1 ( lc( fa 3
APPLICANT SIGNATURE I),NTE-
OFFICE USE: CO1i;IENIS ON PE;RtIFT APPROVAL OR DENIAL
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RENIES `El)BY SA.- TER DIVISION(SIGNATURE) DATE
4
0t TOWN OF YARMOUTH
7 6' HEALTH DEPARTMENT
'' ' i' x PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET
To be completed by Applicant:
Building Site Location: % 13j V& S t Y►914- 0-faV ni--fR � )_e0 75
ProposedImprovement: (40t/C t 3/1)1'' S .M t f �'" � 6( Z'ie
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e IS h cVt d �73 � -17yli
Applicant: iv l> ►�f I .011-Gtr �'�t- S UYL `! Tel No.:
`l t U01? 41 !j, ,:U Wi(,t. 141t9 f t 5
Address: u N ' Date Filed:
Ut R b-A6-0' 6) to 11 i2 (7-1ZG t/V
**If you would like e-mail notification of sign off please provide e-n!R'ail address
Owner Name: /
Owner Address: ) tU'1 L Pit S / Owner Tel. No.: S ,/ - 6"). —
y2 1111 1 >Ch2 t 1.t 7
RESIDENTIAL AND/OR COMMERCIAL BUILDING
HEALTH DEPARTMENT: Determines Compliance to State and Town Regulations; i.e., Requirements
For S,eptage Disposal and other Public Health Activities.
Please submit three (31 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: t" C ;: _ ---- DATE: ,
PLEASE NOTE
COMMENTS/CONDITIONS: