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�•, 40.00 t <br /> Tobin Df-Aag;b lee Date 6 r. <br /> h <br /> Received b <br /> y ° 3 BOARD OF HEALTH <br /> - Hearing Date <br /> 16 GREAT NECK ROAD NORTH =t1. <br /> MASHPEE,MA 02649 f7 d�h <br /> "Ns\jrBLE �� (508)539-1400 EXT.555•FAX(508)477-7380 -�— <br /> .�r3, <br /> ' PUBLIC HEARINGIVARIANCE REQUEST FORM <br /> LOCATION: <br /> Property Address j31 <br /> Assessor's Map and Parcel Number: Size of Lot: <br /> Wetlands Within 300 Ft. Yes ❑ Business Name: <br /> No ❑ Subdivision Name: <br /> Applicant's Name: Phone Number: <br /> Did the owner of the property authorize you to represent him or her? Yes ❑ No ❑ <br /> PROPERTY OWNER'S NAME CONTACT PERSON <br /> Name: w s-rc Name: <br /> Address: Address: <br /> Phone: Phone: <br /> Variance from Regulation (List Regulation) <br /> (Please attach additional sheets If more space is needed) <br /> . T— <br /> NATURE OF WORK `�� <br /> New Construction ❑ House Add./Renovation ❑ Repair of Failed Septic System ❑ <br /> Checklist (To be completed by office staff person receiving variance request application.) <br /> ❑ Four copies of the completed variance request form. <br /> ❑ Two copies of the engineered plans submitted (e.g. septic system plans). <br /> ❑ Two copies of labeled dimensional Floor plans submitted (e.g. house plans or restaurant kitchen plans). <br /> ❑ Signed letter stating that the property owner authorized you to represent him/her for this request. <br /> ❑ Applicant understands that the abutters must be notified by certified mail at least ten days prior to meeting <br /> date at applicants'expense. (For Tide V property line and well variances only.) <br /> ❑ Full menu submitted for grease trap variance requests only. <br /> ❑ Variance request application fee collected. (No fee for variances to repair failed sewage disposal <br /> systems.) <br /> ❑ Variance request submitted at least 15 days prior to meeting date. <br /> C:\word\van=ce request form <br /> I <br />