HomeMy WebLinkAboutBarton Arnold ELIZABETH A. NEVILLE
TOWN CLEI~[
REGISTRAR OF VITAL STATISTICS
........... MARRIAGE OFFIGER .........
RECORDS MANAGEMENT OFFICER
FREEDOM OF INFORMAl 'ION OFFICER
/
~. ~'J 9~OFFI%EoOw~F oTFI~soTu?HW~oLDCLERK
s
Town Hall, 53095 Main Road
P.O. Box 1179
Southold, New York 11971
Fax (63~) 76.5-~!45 .....
T~lephone (631) 765-1800
southoldtown.northfork.net
Residential ~ $10~ or Non-Residential ~ $25__ Application No.Sl'Tq
¢ Permit No.
Applicant Name /~,~.//(· ~~
Applicant Mailing Address ~ ~ ~ ~ ~ ~
Septic Tank or Cesspool__
Brief Description of Proposed Construction or Alteration ....
Location of Proposed Constructj~on/Alteration: _
OwnerofProperty: ,/~'t/~O /
Owner Mailing Address: /,r~
Owner mrope~y Address: ~Z ~f ff~,~
Name and phone number of contact person
Tax Map No: Section /// Block
Cross Street
NOTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. NEW
CONSTRUCTION REQUIRES SURVEY WITH~EAL)P~I ~EP~/vlENT AP~P~ROVAL
Received by: /~~L,. Si~ature o~App~ican~ff ~ate
, N02°18' 18"W