HomeMy WebLinkAboutBOH Permit Application Sign Off 5/6/14 Dominos TOWN OF YARMOUTH
HEALTH DEPARTMENT
PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET
To be completed by Applicant: U fl; 71
Building Site Location: i./ Y /7 V-6 fl Ltt 5 O1/7 A ) oS
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Proposed Improvement: fl,2 W /0 C-0 77 0 11
Applicant: Ira 51 rr)i ` 7)2 h u 1-44/ Dip/71;pp tSTel. No.: 504 —Jr67 1 (!
Address:CS`S 77)0 r n h-e Tfy Q 15 / ) s --�) /4� 01.6 ate Filed: ,3/(//f
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**If you would like e-mail notification of sign off please provide e-mail address: k/_ Gt z h u j&V e ce,J s/n-e-1
Owner Name: —7/4.X. 5 a ' - C „5- it 5A-or --.2./ ,e.-aw�
Owner Address: -I 5 d tC a-- / C Al e / S-S Owner Tel.No SQcP- 5 9 R-5831
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.
REVIEWED BY: DATE: C/67
PLEASE NOTE -
COMMENTS/CCV DITIONS: •
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