HomeMy WebLinkAboutCarpenter Pat ELIZABETH A. NEVILLE ff~- ~~
REGISTRAR OF VITAL STATISTICS ~ ~ 1~ ~ ~-~ ~
FREEDOM OF INFOR~TION OFFICER/]~__ '~ ~ ~
' ,J , J v.....~E OF THE TOWN CLERK
~ APPLICATION
Residential ~ $10 ~or Non-Residential ~ $25 ~
Applicant Mailing Address 27[¢
Septic Tank or Cesspool ~(
Brief Description of Proposed Construction or Alteration
Town Hall, 53095 Main Road
P.O. Box 1179
Southold, New York 11971
Fax (631) 765-6145
Telephone (631) 765-1800
southoldtown.northfork.net
Application No. ,~o2, ~ ~
Permit No.
Location of Proposed Constmctio~.A~pration:
Owner of Property:
Owner Mailing Address:
Owner Property Address:
Name and phone number of contact person
Tax Map No: Section ~o~
Cross Street
70 T - ~3oo ,DOCe~-
Block ~ Lot .2/
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. NEW
CONSTRUCTION REQUIRES SURVfi,~ WITH HEALTH DEPARTMENT APPROVAL
Signature of Applicant Date
Received by:
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