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TOWN OF YARMOUTH
c HEALTH DEPARTMENT
'• MATTA M CSE ''
PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET
To be completed by Applicant:
Building Site Location: 8 /Arr1-0 - S7fl G--)4n LUG / Map No.: Lot No.:
50• y,
Proposed Improvement:
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uc. /rou
Applicant: 1 I' ''I CC__ �i n RJ f'ON an 0/ Tel. No.:CDck- 5—> 3
Address: !Ow)-o- j Gill p er ti-b y . j -.yak-Aio u Date Filed: �y/G 9
**If you would like e-mail notification of sign off please provide e-mail address:
Owner Name: "j°"\`'-'
Owner Address: Owner Tel. No.:
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 four (4) 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: cam/ `1/d '
PLEASE NOTE
COMMENTS/CONDITIONS: