HomeMy WebLinkAboutPermit Application Sign off Transmittal Sheet'aatp''
To be completed by Applicant
Building Site Location:
TOWN OF YARMOUTH
HEALTH DEPARTMENT
PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET
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Applicant: L.^oefn*dv1 G<-,lcr(
Address: lG CLA o.!+\t NltJ\ 026.{B
t'lfyou would like e-mail notificatiotr ofsign of, pleose provide e_moil address
ownerName: 6, US*g
Tel. No.:G81o zall
Date Filed: ?\/>\
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ownerAddress: X QrhA-(bxl err"cu€ownerrel.11o., (tE 3n'q 1?785. q^e$\o {.rFt AA oZ@q
HEALTH DEPARTMENT: Determines Compliance to State and Town Regulations; i.e., RequirementsFor Septage Disposal and other public Health Activities.
RECEIVED
JUI 1 3 2023
HEALTH DEPT,
Please submit three (3) copies of plans, to include:(1.) Site Plan showing existing buildings, water line location,
and septic system locationl(2.) trloor plan labeling ALL rooms within building(all existing and proposed) _
Note: Floor plans not reqaired for decks, sheds, windows, roofingl(3.) If necessary, Tifle 5 application signed by licensed installerwith fee.
REVIEWED BY:DATE:
PLEASE NOTECOMMENTS/CONDITIONS: