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Home My WebLink About25700-Z ~'ORN NO. I TOi~N OF SOUTHOLD BUILDING DEPARTHEHT TOI~N HALL SOUTHOLD, N.Y. 11971 TEL: 765-1802 BOARD OF HEALTH ............... 3 SETS OF PLANS ............... SURVEY ........................ SEPTIC FOR~I ................... NOTIFY: ltllL TO: .................... APPLICATION FOR BUILDING PE~IT~'/' ' ~ l ..... ,_::...:.?:~: I ~a~e ........ :~ .... 3 ~cs of pl~, ~ plot pl~ m ~le. F~ ~i~ ~ b. ~ot plm ~ l~clm of lo~ ~ of ~ildi~ ~ p~,..~s, ~laci~ip ~ M~oini~ ~s or ~lic · is ~li~cim. ~ati~, ~ Co ~JC ~i~ i~t~s m ~s ~ in ~ldi~ for ~s~ in~ti~. .......................... ~ ............ ~ ....... (Si~ of a~li~t, or ~, if a ~rati~) ~ili~ ~=.ess of ~li~t) S~te ~r ~ or --, o~ ~- ~...~... ~¢~ .... ~ ................................................ (~ m ~ ~ mll ~ latest ~) If applic~t is a o~,~,ialim, sigmttn~ of duly authorized officer. ............................... (N~ne and titld'of corporate officer) 3. I~.~ture of ~oek (check ~hich applicoble): Ne~ lJuilding .... ~.. ~iti~ .......... ~terati~ .......... ~ir ............ ~1 ............. ~liti~ ............ Offer ~ ................................... ~ ~ipti~) ....... .............................................. (~o ~ ~id ~ fili~ ~his a~li~i~) 5. II ~lli~, ~r of ~lli~ ~i~s ....~ ...... ~r of ~lli~ ~i~s ~ e~ fl~r ................ 6. If ~i~ss, ~.,,,ercial or ~ ~, ~i~ ~e ~ ~ten~ of ~ ~ of ~ ...................... ?. Di~nsi~s of ~s~i~ s~s, if ~: ~ ................ ~ar ............... ~p~h ................. 1Mi~t ......................... ,.~r o[ S~ories ...................... Di~i~ o~ ~ st~ ~h altera~i~ or ~iti~: ~ ............... ~ar ............... ~pth .................... ~i~ .................... ~r of Stories ............... 8. Di~nsi~ of entire ~ ~t~ti~: ~t .... [/.~ ....... ~ar .... ~[[~ ..... ~p~ ..... ~/ ..... }~i~t .......... ~.~. ........... ~r of Stories ..................... 9. Si~ of lot: ~t .................... ~ .................... ~p~ .................... 10. ~e of ~d~ ..................... ~ of Four ~r ........................................ I I. ~ or ~ dis~ric~ iu ~i~ p~i~s a~ si~t~ .............................................................. 12. ~s ~o~ ~c~ti~ violate ~ ~i~ 1~, o~i~ or ~la~i~: ........................ ]3. ~ill lo~ ~ ~ .................... ~ill ~ fill ~ ~ f~ ~s: ~ ~ ~4. ~s of ~r of pc~,,~s ........................... ~ress .............................. ~ ~ .............. ................ ~ ................. ~ .. ~.~ ........... ~ ~ .............. .............. ......... ....... ............. PLOT DIAGRA~ locate clearly and distinctly all buildings, utmther existing or proposed, mx] indicate all set-back Oi, r~usions property lines. Give street ~d block ~her or description according to dccd, and sho~ street n~res and indicate ~hether interior or corner lot. ~FA'IE 13~ 1~i'714 130UN'I'f ~' ........................ (~ of i~ivi~ml si~ing ~tr~t) (~tr~tor~ ~nt, ~ate offi~r, etc.) ~f ~id ~r or ~rs, ~ is ~ly ~C~ri~ to ~rfom or ~ ~rfo~ ~m ~id w~ ~ to ~ ~ file this ~lication; ~t ail stat~,~nts ~tai~ in ~is s~llcati~ a~ t~ to ~ ~st of his ~1~ ~ ~liefl a~ flint ~ ~ viii ~ ~rfo~ in tim ~r ~t f~r~ ~ ~ a~li~ti~ fil~ ~. ELIZABETH A STATHIS NOTARY PUBLIC. State of New York No. 01 ST6008173, Suffolk _Cou_~ty T~rm Exoires June 8, 20~~o (Signature of ~lie~nt)'