HomeMy WebLinkAbout24021-Z FOIU'! HO. I
TO%4H OF ,(;OU'I'IIOI,D
IIII I 1.1) I fi(; I)EP^RTHI~.NT
'1'O~/Iq IIAI,I.
~OI1'1'1101,1), N.Y. I 19 1 I
TEl,: 765- 1807
Ir, x~sn i~xM ................. , 19 ....
Apprmmd ................. , 19 .... Pe~ml(I~) .................
Di .-,alq.Ov(~l a/c ..................................
TOWN O~ ~OUTHOtD t
(Ik,i hli,,l~ hmpectol)
^i"PI.1 C^T I ON 1;'O1~, Illl I l.I) I fig I'F, IIH I T
! H,q'I'IHJCT I (INS
l~4h,~.It.l) ~)|' II1'.^1.111 ...............
:} !;F.T.q OF' I'l.t~g' ...............
SIIRVIZ, Y ........................
CIII",CK .........................
SEPT1C FORI'I ...................
l)nte ................ , 19 ....
n. 'lid:; api)licnti<x~ .ufll: be ¢'o,q)lelely fill¢~l
'l r;eln of pin,m, accurate plot plan to ncnle. Fee flCCOl-(llnR Io nch~hde.
Ihis nl~fl ication.
c. 'lhe ank c~r~l I~ thla alldicol;io. ~,~y ~t I~ cc~me~g;~l I~fore ismmr~e oF l~lihllng Permit.
d. IIixs~ alq~n~al of this nl~licathm, the l~ihling Insl~¢:l:or will isst~ a Ik~ildlng l'ennlt to Ihe nlqflicnnl;. Such
l~mll ~:hall I~ kept ~ I1~ pr~.i~s ~ailnble for irml~Cti~ Ihr¢~ll~¢s]t the ~g~rk.
e. ~ Ia~ihlh~; ~isall I~ ¢~:~nq~i~l or us~l in ~.~le or in i~rl: for a~ i~Ul~me ~aL~er until a C~rtil'icale off
(~xallg~x;? s~nll have I~n 8ranl:~l by tl~ I~)ihllng hml~clor.
AIq'I.ICATI(~ IS 1~1~;1~ ~E to tie I~iildht8 I~l;Irlnent for Ihe issua~;e of a I~fihlln8 l'ennit la~rmlnnl, lo the
I~i hling 7xs~ Ordi~.~e oF the '1~ off ~alll~l¢l,
I~.gulaLi¢su;, For I1~ cCsmtu~l:iCm of la~i hlis~;, mkll
~k. scril.~l. '11~ npplicm~t agr~s lo c¢~,ldy with all al~llcnble h~s, ordh~m~es, hlilding c¢xle,
lel~dal, ham, m~l to al.iL (a~tl.~rlzml hml~lOra em in'onlnes m~l in h~ihlln8 For ~cesaary inslecti..s.
(.q i p.s~lture of
(tk~i I init ~Kldresa of alq~l ica,,L)
Slale xd.~llmr ~qq~licant in~. les~. ~Renl. n~chltecr, e,,gi,~er, ~e, eral c¢.,trnctor, elecl:ricia., ph,~Is~r o~ I~dh
.................................... .... Co.,.i ............................
~,~ ()(' (~r of [~z~ni~ ............................................................................................
(~ (~ the I.n~ mil o~ latent
IF nl~)li~anl in n c()tlX)rali(m, ~i~tme ()~ duly mlll~)rlzt~l officer.
(ir, l~.~? aftd t it le of coTix~iate ofl'i¢:pr)
........ I ~ ..............
'~- hl - ' ..................... ' ............
FOR POU, ,.D (.b~(.,. E E
BE CO;'4PLETE I:0R C.O.
ALL CON~TRHCTIOli ~,'HAI. L MEET
THE ~EQUiRE~ViE~T~ O~: THE
STATE CONFiTRIJCTiON & EHERGy
CODEs. ,~OT EESPONsIBLE FOR
ix,' i1,~{K ~ ~ _ DESIGN Oil CONSTRUCTION ERRORS
Ihi~ .
C['t~IRE L GLE~