2023 Sign off Transmittal - Dormer TOWN OF YARMOUTH
HEALTH DEPARTMENT
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PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET
To be completed by Applicant: / '
Building Site Location: v� M
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Proposed rovement: p C re c�e !I n1/l ,5 C+C C�(>
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Applicant: .Q� Tel. No.: U _4 -�-% i/
Address: Old /�
60b U/l�f ���GP ICt'- Date Filed: 'd„�
**If you would like e-mail notification of sign off,please provide e-mail address: 5 p CG V rcc 1 .fe II^ (1icp'I
Owner Name: p,me it
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Owner Address: / "l(;c,L e J Owner Tel. No.: 5n 2k710 736
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.
7 �y Please submit three (3) copies of plans, to include:
ilk C'�L.tivtitz (1.) Site Plan showing existing buildings, water line location,
and septic system location;
FEB 3 2023 (2.) Floor plan labeling ALL rooms within building
HEALTH DEPT. (all existing and proposed)—
Note:Floor plans not required for decks, sheds, windows, roofing;
(3.) If necessary, Title 5 application signed by licensed installer
ith fee.
REVIEWED BY: DATE: AE11 3
PLEASE NOTE
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