HomeMy WebLinkAboutBLDC-26-15 Fir' A.q TOWN OF YARMOUTH BUILDING DEPARTMENT
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1., y.__O\ APPLICATION FOR DETERMINATION OF NON-APPLICABILITY
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RP AQUIFER PROTECTION BYLAW 406.5.1.1
Applicant/Business Name: 4 4 K by 1.A., (Ccy I,LC_ Date: 3) /3 f 26
Property Owner: O3zt- '"-T 7tb 1-L- C
Property Location: 9azitt. &e C Unit Map&Lot 0,7 Li a(. 26
Proposed Use: C 4.-to...�� .r ,,4., 0 /✓� ' s4 �re�
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1. Has applicant fully complied with the Submittal Requirements of§406.5.1.1?
(Attach copy of Hazardous Materials List)
2. Are the chemicals,pesticides,fuels and other potentially toxic of hazardous materials used or stored at the
site,or produced by the proposed use,in qualities not greater than those commonly associated with normal
household use? Yes No
3. Does the proposed use meet all of the objectives and water quality criteria of the bylaw?
The above applicant hereby acknowledges that the Building Commissioner may require the applicant to submit the matter
to the Health Agent of Board of Health and may require the applicant to demonstrate that he/she has received a favorable
report from the Health Agent or Board of Health. The Determination,if made, shall apply only to the individual applicant
and proposed use and shall automatically expire upon any change of use or transfer of ownership of the business. There
shall be no appeal from an unfavorable Determination of any such application,nor from a failure to act,except for filing
by the applicant for a Special Permit from the Board of Appeals s otherwise provided herein.
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Applicant Date
2sA 0 S 1 V�i (LA - }2 m O S
Print Name
DETERMINATION• he Building Commissioner,based upon a review of this application and information supplied by
the Applicant,h d rmiri. s that the proposed use satisfies the requirements of§406.5.1.1 and that the Applicant
ed of appl peci � it under§40 2/4 �� GQg i ' 2, ;44
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Building Inspector Date Health Agent Date
Form must be filed with the Town Clerk and copies of this form must be sent to the following departments(as
listed in§406.5.4);Water,Engineering,Fire,Health,Planning,Conservation,Board of Appeals.
Aquifer Protection District Waiver Rev: 07/24
• og YA . TO: Commercial Applicants in the APD
(off FROM: Yarmouth Health Department
y SUBJECT: Hazardous Materials
As part of the application process for a Board of Appeals hearing or Determination of Non-Applicability,
please complete this form and return it with your application. For further information concerning hazardous
materials regulations,contact the Health Department Office.
In the conduct of your present and/or proposed business,do you store,use, or generate any of the following types of
Products? Please check all which apply and list quantities.
Antifreeze,Engine&Radiator Flushes Motor Oil
Hydraulic,Brake,Automatic Trans fluid Gasoline/Fuels
Grease,Lubricants Degreaser/Cleaners
Floor/Driveway Degreaser Battery Acid
Rustproofing/Undercoating Vehicle Detergents
Vehicle Waxes, Polishes Asphalt,Tar, Sealers
Paint,Varnishes, Stains,Dyes,Thinners Wood Preservatives
Dry Cleaning Solvents,Carbon Tetrachloride Floor/Furniture Strippers
Other Cleaning Solvents Rock Salt,Road Salt
Drain,Toilet,Cesspool Cleaners Refrigerants
Bug&Tar Removers Photo Chemicals
Printing Inks&Dyes Pool Chlorine
Pesticides,Insecticides,Herbicides Rodenticide,Fungicides
Nitrate Fertilizer Jewelry Cleaner
Leather Dyes PCBs
Electroplating Sludges Others(List)
Applicant Signature: Date: 0 3 if 3 / 2 h
Rev: 07/24