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HomeMy WebLinkAbout23938-Z FORJ't NO. TO~/I'I ()ir SOUTIIOhl) BI! ! I,[) ] Fl(; [)I~,P^It'I'HEIqT 'I'()~N SOUTIIOI,D, N.Y. !1971 TEh: 765- l)i ,sapl)r~ed n/c .................................. BLDG. DEPT. _T.9,WN OF SOUTHOLD I(lir~b, hml)eCtor) ^PI'I,IC^TION I~(ll{ IIIIII,I) IHG I'EIIHIT I tIS'I'IIUCT 1 OHS CIIECK ......................... ,SIW'rlC FORH ................... Date ................ , 19 .... n. 'lhis nlqHicnl:i(~ ~mmt I)c ctJ~q)letely filial lit hy lying.n-lief or in ink n[xl mll~nill~l 'l ~ln o[ plmm, accurate plot lYla,, I:o stole. F~ nccor(lin~ I:o .ch~lt, le. I). I'lot: I)ln,I ~i~ l~atl(~l of lot nr~! of I~tihlh~s ~ proniseg, relaLioTmhip to mljolnin~ i)rc~nlnen or ix,bi lc thin ;q~)l ication. d. II1.~ nl~rwal of this ni~)licntJ~, the I~HidinR Insl~c~or will ism~ n Ikdldlng l'e~mit I:o the nl~)lica,~t'. ~,,ch ix~[miL ~a,all I~ kept ~ tl~ prenises available for insl~(:ti(~ thr(~.~t tl~ e. ~) I~,il(li~z ~.,11 I~ (~(~,l)i~l or ~,~l in ~)le or in l~rl: for a,~ l~.-ix)se ~mi~er (k:(:Ul~.~:y ~mll have I~n {~rnnt~l hy I1~ Ihdl(linR hml~Cl:or. AI'Iq,I(~TI(~ I~ la~l~lW ~ to tl~ b,ihli,,8 Ikl~arllms~t r.r the i~msa[~:e of n I~,ihling l'emit I~,rmmr, t to the I~H hli,~{~ ~x.~ Ordi,m[~e o~ tl~ 'ltx~l off ~x~lhohl, ~ffolk (~,nty, ~m~ York, n,~l other a~)licable I~{~ulal:i(.m. for I1~ c~mts't~ti~] of I~Hhli~g., mkliti(~m or alleral:io, m,-or for r~,~al or d~olltio,~, n~ I~rein <~scril~l. '11~ ~ppllcant ni~r~ lo co,~ly wilh all al~)l icable I~., ordhm~e~, Ix, il(ling c(xle, reR. lal. i(.m, n,~i to mi.il: m,tl~)ri~l hml~cLors (~ F~ni~es n[~l {,] I~Hldi.~ for ~(:es~.~ (}'h,m taxi t it le of corl~orate officer) I~,l.,~., uf I,~fk (dm.(:k ~.dlic:Jl i)l,plic.hle): I&~., I~lihlitq~ .......... AHditi~,. .......... Alterati(.~ .......... ,~., i,,~,,,., ~,~,, ......................... ~ ~ . ~ I~ ~,~.~ .............................................. (Iii I~ I~Ji~l I,I I:ili.l~ Ihi. hppl 1~ Jxmi~K~.Ji, c(~m.rci~J o[' iuJ~(I (x:(:(il~ll~y' .l~ci~y n~Hl*~ m~l e.len[ ~)~ .ach [yl~ ()~ mJ~ ...................... I)i.x~,.iij.j. ()l= e.J.li~ zdlJK~[m~., i(: -Hy: FH.~( ................ I~eaJ' . .............. I~plh ................. I~tplh .................... I~ii~H .................... ~i,~l.~r ~1: ~l~rJ~J ............... IJill I(~l I~ ,ellrm~(I ........ ~ P ....... ~lill (~:es. f il I I.i r~,,we(I frl,,~ ill.iii.e.: YES I~,,.~. (if (l,,~, ,if I.(~.i~~ ~..~ ,~ ,~N~.p~.O~C. ~l,e.~ ~'().'~ II'~t~'~c~i~ II,(~ tko. ~-~0 C o ~ i~.' ................... ~'(~ ~ ................ N~lJl~ ()J~ Al-(:hil~('.( .................................... ~ll'(~t8 .............................. I~lolV~ Jj) ............... Jl;.ll~ Iii: (it,ll F~J(:J()[ ................................... ~Jr(tB~ ............................... lll()[~ ~) ............... ~ IF YES, ~{~IllJ8 i) 'lJ~'l 'li~l~'ll~J Iq~l~l'l' }'~Y I~ I~?l~lll{El). (h]ly .',~.~)ln, (l(?lX).~;(_~i ;u.I .'J;ly.~; Ih;It h(? i:; Ih(! Ik~ i;; Iii,:(Ik,,,! il(:[ ~ ~ ~--~ ;qq)l [t;;It it.i; thtll ~ilJ .(al(~lt~nt. (:(,,taiJ~M i,) Ihi~ .ppi i(:~ll iutl ~lr(~ I ziK~ t() the I~t.l: of: hill k,x~l~ll:e JJl~l I~}l icl; ~,,~1 Ih~H tJlt~ ~),1( will Im i~rJ:lillll~(I ill IJle ii~)nl~[' llel: I:()Jlll Jl~ IJie ~1)1)1 i[:~]l:io,~ fi le(I Ih(~'wilh. r "~ ~ ~: , / ~,o~ ~ ~