HomeMy WebLinkAbout2015 Jun 15 - Sign Off Transmittal Sheet ��.�_n�.��
=o4�qR,� TOWN OF>YARMOUTH
-�O HEALTH DEPARTMENT
O-L . . , -�.�y
� ''�� ••`` � PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET
To be completed by Applicant:
Building Site L,ocation: � � ���� Y C�, \�ML,� Ci u�� 7 G �'YY`O�i}�
Proposed Improvement: �.A Y�'� JU-e, �n,Cn 11 ScC �L Q�'� �'1G ��n � +�i 6 �C� v �b`M S
�� i4�5- � p.� SY� r1, lnG� Mq r�k �
Applicant: �CT(� �f'C��YYIG Y1 Te1.No.:�y- ��-E,S�Sq
aaare�s: 1S ��t�ca`� Wc�. � ��vw�C�nt��kl (�a��1S vateFiled: bb IS 1 �
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**Ifyou would[ike e-mail notrfication ofsign oJj,please provide e-mael address: j
Owner Name:�� Jh�1 Mc'�y1�v_�W S I
OwnerAddress: I a S �CYYA W(7V.A WP�� vGV��1h MY� t���30wnerTel.No.: �,1�1-���- I �d �
RESIDENTIAL AND/OR COMMERCIAL BUII.DING
HEALTH DEPARTMENT: Deternunes Compliance to State and Town RegulaUons; i.e.,Requirements
'� For Septage Disposal and other Public Health Activities.
I
Please submit three (3) copies of plans, to include:
(1.) Site Plan showing existing buildings,water line location,
cand septic system location;
� ' or� n ALL rooms v�ithin buildin
A � ; , ��•) �l9, . �1��°(� b g
(all exishng and proposed)—
Note:Floor plans not required for decks,sheds, windows, roofuig;
(3.) If necessary, Title 5 application signed by licensed inst�ller
with fee.
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REVIEWEDBY:�� DATE:�IS //S
PLEASE NOTE
COMMENTS/CONDITIONS: 2 ^�
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